Geriatric Nursing Midterm

8/6/2019 Geriatric Nursing Midterm

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Care of the Chronically Ill and

the Older PersonsELECTIVE 2BSN 14B

July 20, 2011


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Risk factors associated in

Chronic Illness in elderly

Modifiable/non-modifiable


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Risk factors: Modifiable

Lifestyle

Smoking

Poor nutritionPhysical inactivity

Failure to use preventive and screening

services

Coping styles, stress


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Risk factors: Non-modifiable

Age

Pre-existing conditions

Long term medication

Hereditary


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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


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Comprehensive Geriatric

Assessment


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Assessment A multidimensional, interdisciplinary

diagnostic process to determine the:

MedicalPsychological

Functional capabilities of a frail elderly

person


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AssessmentPurpose

Develop a coordinated and integrated plan

for treatment and long-term follow-up Achieve quality and functional status of life


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AssessmentPurpose

Determine prognosis and outcome of care

Employment of interdisciplinary teams Utilize standardized instruments to

evaluate aspects of patient functioning,

impairments, and social supports


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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


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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


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COMPONENTS OF

COMPREHENSIVE ASSESSMENT

Component Elements

Medical assessment Problem list

Comorbid conditions and disease severity

Medication review

Nutritional status

Assessment of functioning Basic activities of daily living

Instrumental activities of daily living

Activity/exercise status

Gait and balance

Psychological assessment Mental status (cognitive) testing

Mood/depression testing

Social assessment Informal support needs and assets

Care resource eligibility/financial assessment

Environmental assessment Home safety

Transportation and telehealth


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CHRONIC ILLNESS IN

ELDERLY


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Wellness is the Goal at All Ages

Spiritual

Faith

Meaning in life

EmotionalFriendship

Connections to others

Sense of well being

Belonging to a family

and community

Physical

Nutrition

Exercise

Mental

Activities and hobbiesProblem-solving

Continuing education

Financial

Security

IndependenceFlexibility

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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 maybe corrected or relieved

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Being an older adult,Does not mean being ill!


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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% nationalhealth care costs


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Not just long-term conditions

Co-morbidity

Complexity

Frailty


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And for the next steps..


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Unlike Acute Illness.

Short-term

Either die or get

well Influenza

Pneumonia

GI infections


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Chronic Illness

Persists for a long

time and is either

incurable and/orresults in

pathological

changes that limit

normal functioning.

Virtually everyone

will eventually

develop some typeof chronic

condition.


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Differences between acute and

chronic conditionsAcute disease Chronic Illness

Onset Abrupt Generally gradual and insidious

Duration Limited Lengthy and indefiniteCause Usually single Usually multiple and changes over

time

Diagnosis &

prognosis

Usually accurate Often uncertain

Intervention Usually effective Often indecisive; adverse effectscommon

Outcome Cure possible No cure

Uncertainty Minimal Pervasive

Knowledge Prof.s - knowledgeable

Patients - inexperienced

Prof.s and patients have comple-

mentary knowledge and experience


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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


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BiggestWorries About Having A

Chronic Illness (Age 50 +)

1. Losing independence

2. Being burden to family or

friends

3. Affording medical care


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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%)


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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 toolong, they can have an

negative effect on the

illness


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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


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The Impact of Chronic Illness - The

Family

Must adjust to:

Increased stress

Change in thenature 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


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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


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..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


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Informed,

ActivatedPatient

Productive

Interactions

Prepared,

ProactivePractice Team

Delivery

System

Design

Decision

Support

Clinical

Information

Systems

Self-

Management

Support

Health System

Resources and

Policies

Community

Health Care Organization

Chronic Care Model

Improved Outcomes


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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, sitevisits to selected group

Model applied with diabetes, depression, asthma,

CHF, CVD, arthritis, and geriatrics


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Essential Element of Good

Chronic Illness Care

Informed,Activated

Patient

ProductiveInteractions

PreparedPractice

Team


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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

PatientProductive

Interactions

Prepared

Practice

Team

What is a productive interaction?


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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


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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 fitstheir culture


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Decision Support

Embed evidence-based guidelines into

daily clinical practice

Integrate specialist expertise and primarycare

Use proven provider education methods

Share guidelines and information withpatients


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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


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Community Resources and

Policies Encourage patients to participate ineffective programs

Form partnerships with communityorganizations to support or develop

programs

Advocate for policies to improve care


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Chronic illness by SYSTEM


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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 Foundation

www.nof.org/osteoporosis44


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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 thanmen

One in three women and one in 12 menover the age of 50

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Family History and Personal History ofFractures as an Adult:

Women whose mothers have a history of

vertebral fractures seem to have reducedbone mass

Personal history of a fracture as an adult

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Race

Caucasian and Asian women are morelikely to develop osteoporosis

African American and Hispanic women atsignificant risk

Bone structure and body weight

Small-boned and thin women (under 127pounds)

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Lifestyle:

Cigarette smoking, alcohol abuse,

consuming an inadequate amount ofcalcium or getting little or no weight-bearingexercise

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 mostcommonly 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; usuallyaffects the big toe

Causes severe pain and swelling in thatjoint

Ankylosing Spondylitis Degeneration of the joints that support, and

are part of, the spinal column

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Risk Factors for Arthritis:

Certain foods

Hormonal changes

Heredity

Gender

Age


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Treatment

Adequate rest

Stretching and daily ROM exercises

Maintaining ideal weight

Taking aspirin and ibuprofen

Hot and cold treatments for minordiscomfort

Over-the-counter preparations containingcapsicum, camphor, or menthol

For more severe cases, corticosteroid

injections to fight inflammation55

Often the symptoms of

arthritis can be relieved

by basic self-care practices


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Call a doctor when

Pain is accompanied by fever

Sudden unexplained swelling, redness or pain inany 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 sixweeks 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


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Hypertension

(Blood Pressure above 140/90)

Cause unknown

If untreated, is related to development of arteriosclerosis

If untreated, may cause stroke, heart attack, congestiveheart failure, and/or kidney failure

Treatment: medication

low salt diet

exercise

stress management weight management

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Signs and Symptoms of StrokeAmerican Stroke Association

Sudden onset of: Numbness or weakness of face, arm or leg, especially on one sideof 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 thespeed of onset (minutes or hours vs. several days)

Brief loss of consciousness or period of decreased consciousness

(fainting, confusion, convulsions or coma)

TIA Transient IschemicAttack (small stroke)

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T t t d R h bilit ti


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Treatment and Rehabilitation

Rehabilitation:

Physical therapy (PT) to restore physical functioning and skills likewalking and range of movement

Occupational therapy (OT) to relearn the skills needed foreveryday living such as eating, toileting, dressing and taking careof 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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AphasiaAmerican 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 abletothink as well asbeforethestroke,

may experience aninterferenceintheuseorunderstanding oflanguage Theindividualis unable

to gettherightwordsoutorisunableto processwordscoming in

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Si d S t f H t Att k


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Signs and Symptoms of a Heart AttackAmerican Heart Association

Discomfort in the center of the chest that lastsmore than a few minutes

Discomfort in other areas of the upper body inone or both arms, the back, neck, jaw or stomach

Shortness of breath accompanied by chest

discomfort or can occur before the chestdiscomfort

Breaking out in a cold sweat, nausea orlightheadedness

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 ishigher for women than men

As with men, women's most commonheart attack symptom is chest pain ordiscomfort

Women are somewhat more likely thanmen to experience some of the othercommon symptoms, particularlyshortness 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 aclear 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 theheart (arteriosclerosis)

Brought on by exertion, cold, eating a heavy meal or

excitement

Management strategies: Losing weight, stopping smokingand managing stress

Response Nitroglycerin tabletis placed under the tongue and

allowed to dissolve Works in

one-half to three minutes

Response Nitroglycerin tabletis placed under the tongue and

allowed to dissolve Works in

one-half to three minutes

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A i Di b t


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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 surgerymay 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

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Geriatric Nursing Midterm

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