Geriatric Syndromes and Special Needs 10 15 2010 HANDOUT

Geriatric Syndromes and Special Needs 10 15 2010 HANDOUT -...

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Unformatted text preview: Geriatric Syndromes and Special Needs of the Older Adult Adult Barb Heise, PhD, FNP, PMHCNS Thought for the Day Thought The Little Boy and the Old Man Said the little boy, “Sometimes I drop my spoon.” Said the little old man, “I do that too.” The little boy whispered, “I wet my pants.” “I do that too,” laughed the little old man. Said the little boy, “I often cry.” The old man nodded, “So do I.” “But worst of all,” said the boy, “it seems Grown­ups don’t pay attention to me.” And he felt the warmth of a wrinkled old hand, “I know what you mean,” said the little old man. Shel Silverstein Objectives Objectives Define Geriatric Syndromes Falls • • • • • • Identify Risk factors for falls Discuss fall assessment Recognize environmental hazards Indentify nursing interventions to prevent falls Discuss use of restraints Develop nursing care plan for Risk of Injury, Falls Falls Falls “A fall may be viewed as a sentinel event in the life of an older person, potentially marking the beginning of a serious decline in function.” Falls Falls Accidents: 5th Leading cause of Death in Elderly. 2/3 of these are falls Mortality: If over 75 y/o, 50% die within one year of a hip fracture 84% of all adverse inpatient incidents are falls 67% of nursing home residents fall each year Risk Factors for Falls in Older Adults Older Intrinsic Extrinsic • Impaired mobility/ gait/balance • Acute/chronic illness • Environmental Factors Lighting Throw rugs Footwear Cluttered environment • • • Medications/ alcohol Fall History Frailty Visual/sensory/ neuro/cognitive impairment Influence postural stability • • • Use of assistive devices Restraints Siderails Complications R/T Falls Complications • • Prolonged Bedrest Injury: Deconditioning • • • • Pneumonia Discomfort/pain Dependency Immobility Fractures Soft­tissue damage Assessment Assessment Cognitive, sensory and mobility status Mood Fall Risk: reassess ________________ Gait/Balance Alcohol Use Environment Client and caregiver understanding of fall risk and prevention strategies Preventing Injury in the Home Preventing Getting Rid of Hazards Making things easier to do Having an emergency plan Getting help Identify Hazards Identify Cluttered pathways Slippery floors Loose throw rugs Poor lighting Items out of reach No smoke detectors Improper foot wear Making Things Easier Making Light switches that light up Touch­on lamps Handy flashlights Night lights Frequently used items within reach Emergency phone number list by phones Personal Medical Alert System Fall Prevention and Interventions: Fall Identify persons at high risk Assess gait and balance Medication Review Assistive devices for sensory deficits Assistive devices for ambulation Evaluate continence needs and establish a toileting schedule Safety evaluation of environment Restorative therapy/ exercise Risk for Falls r/t unsteady gait m/b statements of “Help” Interventions • • • • • • • Perform Fall Risk Assessment Assess via Get Up and Go test Assess for orthostatic hypotension Assess for anemia Assess for chronic alcohol intake Refer to physical therapy for strength training Encourage use of walking aids such as cane, walker, Canadian crutches. Restraints Restraints Physical • • • • • Vests Belts Mitts Specialized Chairs Bed Rails Restraints Restraints Signed, dated MD order specifying restrain AND time limit for use. Client must be reevaluated at that time to determine if less restrictive method appropriate Remove restrains for 10 minutes q 2 hours for ROM, etc. Document rationale for restraint; other methods tried; client response & preventative care Restraints Restraints Chemical • Medication GOAL: Restraint­free environment Objectives Objectives Sleep • • • • • Discuss sleep changes associated w/ aging Identify causes of sleep alterations Discuss sleep apnea & its consequences Discuss the sleep assessment Identify nursing interventions to promote sleep Sleep Problems in Older Adults Sleep Common: >50% older adults 12­25% report chronic insomnia which increases w/ chronic illnesses Sleep in America (2003) 67% w/ sleep disturbance but only 1:8 diagnosed by MD Key Words Key REM (Rapid Eye Movement) NREM (Non Rapid Eye Movement) Circadian rhythm Insomnia Sleep apnea • Obstructive • Central Stages of Sleep Stages Stage 1: Light sleep. Easily awakened Stage 2: Medium deep sleep. Minutes p stage 1. Asleep but easily aroused Stage 3: Medium deep sleep. 20 minutes p stage 1. Undisturbed w/ moderate stimuli Stage 4: Deep sleep. Awaken w/ vigorous stimuli. Lasts 10­ 20 min. Most nightmares, sleepwalking, bedwetting occurs Stage 5: Active sleep. REM. Drifts up from stage 4 q 90­100 min. Dreaming. Talk in sleep. Normal Age Related Normal Sleep Changes Increase in stage I sleep Decrease in Stage III and IV and REM sleep Greater difficulty falling asleep More frequent awakenings Decreased nighttime sleep Increased daytime napping Causes of Sleep Alterations Causes Medications Comorbid medical problems (partial list) • • • • • • • • Dementia Depression/Anxiety Alcohol Abuse Cardiovascular disease COPD Diabetes GERD Arthritis Common Sleep Problems Insomnia: most common Sleep apnea • • • • Transient Chronic Restless Leg Syndrome (RLS) Periodic Limb Movements (PLMS) Obstructive (OSA) Central Sleep Assessment Sleep Sleep History Medical History Diet and Drug History Psychosocial History Sleep Hygiene Sleep Develop a bedtime routine • • • Change into night clothes Wash face; brush teeth Go to the Bathroom Use the bedroom for sleep only. Carry out other activities such as watching TV or reading in another room. Sleep Hygiene Sleep Discourage daytime napping Use relaxation techniques Exercise but not just before bedtime Try to sleep x 30 minutes. If not asleep get up and out of the bedroom and do something quiet such as reading. Then go back and try again for 30 minutes. Nursing Interventions to Promote Sleep Nursing Remove contributing factors • • • • Tx medical illness Assess medications Alcohol/caffeine/nicotine Exercise Patient Education: Sleep Diary Sleep Hygiene CBT Pharmacologic Option • Short term use Objectives Objectives Pain • • • • • • Define the concept of pain List types of pain and pain characteristics Differentiate between acute & chronic pain Discuss goals for pain management Discuss comfort & relaxation techniques Develop a nursing care plan for older adults in pain Dull T H ROBBI N G SHARP BURNI NG STABBI NG Aching Cr ushing PAI N Pain Prevalence Pain Common: Prevalence of chronic pain increases with age 50% of community dwelling older adults have pain Among nursing home residents 70­80% have pain Osteoarthritis: most common disorder associated with pain in older adults Concept of Pain Concept Subjective Sensory, physical, psychosocial, emotional and spiritual components Margo McCaffery: Pain is whatever the person says it is. 5th Vital Sign Types of Pain Types Acute: time limited. Easily controlled with analgesics Persistent: aka Chronic pain. No time frame. Varying levels of intensity. Multifactorial. Malignant or non­malignant origin. Breakthrough Pain Types of Persistent Pain Types Nociceptive: Identifiable tissue damage or inflammation. Neuropathic: Dysfunction in the PNS or CNS Mixed: Nociceptive and Neuropathic. Example: Compression Fractures Conditions Associated with Pain in Older Adults in DJD/Osteoarthritis RA Chronic Back Pain Osteoporosis DM GERD PVD Chronic Constipation Post­stroke Syndrome Immobility Headache Oral/gum disease Amputation Angina/CAD Cancer pain Pain Assessment Pain TIMING ­Onset, duration, course, pattern LOCATION­focal, multifocal, generalized, referred, superficial, deep INTENSITY– rate on scale: average, least, worst, & current pain level QUALITY– aching, throbbing, stabbing, burning, stinging, shooting, tingling. AGGRAVATING/ALLEVIATING factors– position, activity, weight bearing, cutaneous stimulation ASSOCIATED SYMPTOMS­ N/V, sleep, appetite, emotions PREVIOUS RESPONSE­ what helped in the past MEANING of the pain­ punishment? Expected? Ask about pain regularly and what relieves it family and setting fashion ABC’s of Pain ABC’s Assess pain systematically Believe the patient and family in their reports of pain Choose pain control options appropriate for the patient, D eliver interventions in a timely, logical, coordinated Empow er patients Enable patients to control their pain control to patients to control their pain control to greatest extent possible the Pain Management Principles Pain Goal: Relieve and prevent pain Person with pain is the expert Adjust med to individual response Combine med with non­drug interventions Pain medication works best when po & administered continuously Managing Chronic Pain: Patient Perspective Patient Accept the pain Get Involved Learn to Set Priorities Set Realistic Goals Know your Basic Rights Recognize emotions Learn to Relax Exercise See the total picture Reach Out Ten Steps from Patient to Person. American Chronic Pain Association Barriers to Pain Relief Belief that older patients experience less pain Older patients cannot tolerate opioids Failure to use standardized assessment tools Pain medications are addictive Analgesics are more effective when administered regularly before pain becomes severe Ineffective Coping Ineffective Nursing Diagnosis: Ineffective coping r/t chronic pain m/b increased isolation Interventions • Establish a therapeutic relationship. Encourage talking re: feelings & what is happening. • Increase & mobilize support system • Assess for depressive sxs and SI • Provide pain med as ordered & use non­med pain reduction techniques • Use active listening and acceptance • Provide activities within pts capabilities Pain in People with Dementia Pain Myth: clients with dementia cannot be assessed for pain Misinterpretation of cognitively impaired person’s behavior as being unrelated to pain No decrease in experiences of pain but may have decreased ability to report pain Pain and the Cognitively Impaired Do Not assume that those who cannot verbalize pain don’t have pain Pain Cues: (in addition to other cues) • • • • • • Aggressive behavior Restlessness/agitation Resists care Change in appetite Change in sleep pattern Silence Adverse Consequences associated with Pain in Seniors with Decreased quality of Life Decreased socialization Sleep disturbance Impaired ambulation Suicidal Ideation Decreased appetite and food intake Increased healthcare utilization and costs Analgesic Ladder Ladder Non-Pharmacological Strategies Non-Pharmacological Education Cognitive Programs: biofeedback, hypnosis, relaxation techniques Exercise Acupuncture TENS Chiropractic Physical methods: heat, cold, massage Sample Care Plan Sample Date Nsg Diagnosis 10­ 16 Chronic Pain r/t swollen joints m/b “it hurts to walk” per client. Goal Resident will express relief of pain (less than 3:10) by next shift (10/17/09) Intervention Assess pain level. Administer analgesics as ordered. Monitor for analgesic effectiveness & side effects. Instruct in guided “ We all must die. But if I can save him from “ days of torture, that is what I feel is my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.” Albert Schweitzer Delirium Delirium Objectives 1. 2. 3. 4. Identify prevalence and types of delirium Discuss the signs & symptoms of delirium Identify steps to prevent delirium Identify nursing interventions for the care of the person with delirium Delirium Delirium Prevalence Occurs in 10% to 40% of patients over 65 years old upon admission. 25% to 60% develop delirium after hospitalization. Most at risk are older persons who have fallen and sustained a hip fracture. Insel, K. C., & Badger, T. S. (2002). Deciphering the 4 D’s: cognitive decline, delirium, depression and dementia – a review. Journal of Advanced Nursing, 38(4), 360­368. Delirium Defined Delirium Acute confusional state Mental disturbances characterized by __________, disturbed consciousness, impaired cognition, and an __________ underlying medical cause (medications, anesthesia, sleep disturbance, electrolyte imbalance, etc.). Delirium is a _____________________. Types of Delirium Types Hyperactive Hypoactive Mixed • • • • Increased response to stimuli Increased psychomotor activity Decreased alertness Decreased psychomotor activity Risk Factors for Delirium Risk Pre­existing cognitive decline Advanced age Male gender Greater medication use Co­morbidity Acute illness Sensory Deficits Possible Causes of Delirium Possible Unfamiliar surroundings Medications Fluid/electrolyte imbalance Infection CHF Pain Malnutrition/ dehydration Hypoxia Anemia Stress Foley Catheter Precipitating Factors Precipitating Predict the development of delirium • • • • • Immobility Malnutrition/ dehydration More than 3 medications added Use of bladder catheter Any iatrogenic event during hospitalization Abrupt onset Time limited: usually < 1 month Often associated w/ acute illness, medications or change in environment Disoriented/ disorganized thinking Disturbed sleep Confusion fluctuates ______________ Short attention span…easily distracted Loud or incoherent speech Cognitive and perceptual changes Characteristics of Delirium Characteristics S & S of Delirium of Disoriented to time and place Altered attention Impaired memory Mood swings Poor judgment Altered level of consciousness (LOC) Delirium Assessment Delirium Comprehensive History and Physical Review all medications Evaluate Labs: CBC, electrolytes, liver & renal function tests, serum calcium & glucose Evaluate CXR, EKG and O2 sats CAM (Confusion Assessment Method) Identify underlying cause Ensure safety Reduce stimulation Reorient to surroundings. Adequate hydration and nutrition Familiar items or people Medications: low dose neuroleptics (Haldol, atypicals such as risperidone). AVOID Thorazine and Mellaril Delirium Treatment Delirium Pain is Inevitable Pain is Inevitable Misery is an Option ...
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