Dee Tucker RN, MS, GCNS-BC Nursing Service An Overall Assessment Tool of  Older Adults SPICES
SPICES <ul><li>Use as a  screen  for the most frequently occurring health problems in hospitalized older adults   </li></ul>
SPICES <ul><li>Screen daily. </li></ul><ul><li>Follow up with further assessment. </li></ul><ul><li>Initiate preventive an...
SPICES Interventions Assessment S leep Disorders P roblems with Eating/Feeding,  P ain I ncontinence C ognition E vidence ...
SPICES Interventions Assessment S leep Disorders Restless or  wake-sleep cycle disturbance Sleep protocol Evaluate for cau...
SPICES Interventions Assessment P roblems with Eating/ Feeding,  P ain % food eaten for each meal last  24hr PO fluid inta...
SPICES Interventions Assessment I ncontinence Any episode Foley catheter Begin Toileting schedule Evaluate for UTI DC’ing ...
SPICES Interventions Assessment E vidence of Falls, Mobility problems Orthostatic BP & pulse Function & mobility as observ...
SPICES <ul><li>Questions? </li></ul><ul><li>Tell me what you’ve learned. </li></ul><ul><li>Thank You </li></ul>
Atypical Disease Presentation in Older Adults Dee Tucker, MS, RN, GCNS-BC Nursing Administration
Atypical Disease Presentation <ul><li>By assessing older patients for atypical presentations, nurses provide appropriate i...
Signs and Symptoms Learn baseline prior to illness Remember aging changes Recognize presenting symptoms
Baseline prior to illness <ul><li>Variability </li></ul><ul><li>Verify </li></ul><ul><li>Frailty </li></ul>
Aging Effect <ul><li>Non specific </li></ul><ul><li>Less acute </li></ul><ul><li>Slow to present </li></ul>
Presenting Symptoms Signs and symptoms in older patients are generalized and can represent any number of medical situations.
Atypical Disease Presentation <ul><li>Infections </li></ul>Urinary Tract Respiratory Skin
UTI The older kidney has less concentrated urine. <ul><li>Kidneys do not conserve water as well </li></ul><ul><li>Increase...
UTI <ul><li>Symptoms </li></ul><ul><li>tired, poor appetite,  perhaps  abdominal discomfort,  perhaps  foul smell to urine...
Respiratory Infection BLUE represents amount of air inhaled RED represents lungs PINK represents the diaphragm
Respiratory Infection <ul><li>Symptoms </li></ul><ul><li>tired, poor appetite,  perhaps  cough,  perhaps  shortness of bre...
Skin Infection <ul><li>Symptoms </li></ul><ul><li>tired, some tenderness </li></ul><ul><li>Signs </li></ul><ul><li>increas...
Atypical Disease Presentation <ul><li>Cardiac Issues </li></ul>Heart Failure with pulmonary edema Myocardial Infarction Pu...
Heart Failure with Pulmonary Edema <ul><li>Symptoms </li></ul><ul><li>tired, poor appetite,  perhaps  shortness of breathe...
Myocardial Infarction <ul><li>Symptoms </li></ul><ul><li>fatigue, weak, restless, shortness of breath,  perhaps  pain  </l...
Pulmonary Emboli <ul><li>Symptoms:  perhaps  chest pain with inspiration,  perhaps  shortness of breath </li></ul><ul><li>...
Case <ul><li>86 yo man is admitted for c/o progressive weakness and fatigue: unable to carry out his normal daily activiti...
Case <ul><li>He is cooperative, pleasant and looks quite well. No history of dyspnea or coughing. He has an IV going and w...
Symptom Presentation in Older Adults <ul><li>Baseline: independent ADLs, IADLs, very active self sufficient; no dyspnea or...
Clinical Pearls <ul><li>Symptoms: vague, less acute, slow to present </li></ul><ul><li>Compare to normal baseline </li></u...
Delirium: Can You Recognize Acute Confusion? Dee Tucker, MS, RN, GCNS-BC Nursing Administration
Delirium: Risk <ul><li>Normal Aging Changes </li></ul><ul><li>Environment </li></ul><ul><li>Medications </li></ul><ul><li>...
3 Types of Delirium <ul><li>Hyperalert, hyperactive </li></ul><ul><li>Hypoactive, hypoalert </li></ul><ul><li>Mixed </li><...
Prevention <ul><li>Ensure hydration and nutrition  </li></ul><ul><li>Mobilize  </li></ul><ul><li>Support Cognition </li></...
Assessment  <ul><li>Baseline </li></ul><ul><li>Cognition </li></ul><ul><li>Function </li></ul><ul><li>Mobility </li></ul>
Assessment for Delirium <ul><li>CAM  Confusion Assessment Method </li></ul><ul><li>Acute onset; fluctuating </li></ul><ul>...
CAM <ul><li>1 st  Sudden Onset </li></ul><ul><li>After admission </li></ul><ul><li>Prior to admission </li></ul><ul><li>If...
CAM <ul><li>2 nd   Inattention </li></ul><ul><li>Tests of attention  </li></ul><ul><ul><li>Count backwards from 20. </li><...
CAM <ul><li>3 rd   Disorganized Thinking </li></ul><ul><li>Clinical evaluation of conversation </li></ul><ul><li>Sets of Q...
CAM <ul><li>4 th  Altered Level of Consciousness  </li></ul><ul><li>Anything other than alert = positive </li></ul><ul><li...
CAM <ul><li>CAM  Confusion Assessment Method </li></ul><ul><li>Acute onset; fluctuating </li></ul><ul><li>Inattentive </li...
Assessment Frequency <ul><li>Admission </li></ul><ul><li>Daily </li></ul><ul><li>With behaviors changes </li></ul>
Documenting <ul><li>Specific behaviors -Avoid general terms i.e.  confusion, disoriented </li></ul><ul><li>Alert vs attent...
Interventions with Delirium <ul><li>Collaboration </li></ul><ul><li>Safe environment </li></ul><ul><li>Prevent complicatio...
Interventions with Delirium <ul><li>Collaboration </li></ul><ul><li>Ask pharmacist to review meds </li></ul><ul><li>Check ...
Interventions with Delirium <ul><li>Safe Environment </li></ul><ul><li>Orient frequently, Reassure, family Room near nurse...
Interventions with Delirium <ul><li>Prevent  Complications </li></ul><ul><li>Hydration/ Fluid balance </li></ul><ul><li>Nu...
What Do You Think? <ul><li>1. Nurses must learn to recognize signs of delirium in older adults because: </li></ul><ul><ul>...
What Do You Think? <ul><li>2. The following are possible precipitating causes of delirium in elders: </li></ul><ul><ul><li...
What Do You Think? <ul><li>3. Patients with dementia are at increased risk for developing delirium. </li></ul><ul><ul><li>...
What Do You Think? <ul><li>4. What is the cardinal sign of delirium? </li></ul><ul><ul><li>a. Change in baseline cognition...
What Do You Think? <ul><li>5. Which of the following predisposes older adults to delirium? </li></ul><ul><ul><li>a. Cognit...
Delirium <ul><li>ALL  older patients at risk  </li></ul><ul><li>Baseline prior to illness </li></ul><ul><li>Use CAM </li><...
Depression
Incidence <ul><li>60 million Americans greater than 65 yrs. </li></ul><ul><li>Only 10% of these receive treatment </li></u...
Definition <ul><li>Clinical syndrome characterized by lower mood tone, difficulty thinking, and somatic changes precipitat...
Symptoms of Depression <ul><li>Feeling of worthlessness or sadness </li></ul><ul><li>Loss of interest or pleasure in activ...
Diagnosis Challenges <ul><li>Concurrent medical illness with overlapping symptoms of depression </li></ul><ul><li>Medicati...
Risk Factors <ul><li>Female sex </li></ul><ul><li>Social isolation </li></ul><ul><li>Unemployment or retirement </li></ul>...
Causes of Depression <ul><li>Many different theories, Many different causes </li></ul><ul><li>Brain neurotransmitter imbal...
Vascular Depression <ul><li>Importance of chronic ischemic cerebral changes only recently recognized </li></ul><ul><li>Mos...
Pharmacologic Treatment <ul><li>SSRI’s – Celexa, Lexapro, Zoloft, Paxil, Prozac </li></ul><ul><li>SNRI’s – Effexor, Cymbal...
Other Medication Considerations <ul><li>Start low and go slow </li></ul><ul><li>Explain temporary side effects to encourag...
Other Forms of Treatment <ul><li>Psychotherapy : individual and/or group </li></ul><ul><li>Problem – Medicare and other in...
What can we do ? <ul><li>Screening </li></ul><ul><li>SPICES </li></ul><ul><li>Enhance physical function and social support...
 
“ SIG-E-CAPS” <ul><li>Acronym for evaluating patient’s progress </li></ul><ul><li>S  Sleep disturbances </li></ul><ul><li>...
 
Nutrition and Hydration in the Older Adult
Definitions <ul><li>Malnutrition : any disorder of nutrition status, including disorders resulting from inadequate intake ...
Demographics <ul><li>Malnutrition in Older Adults: </li></ul><ul><ul><li>Independent Living: 1% TO 15% </li></ul></ul><ul>...
Increased Risks <ul><li>Older adults who are malnourished are more likely to experience: </li></ul><ul><ul><li>Longer hosp...
Increased Risks <ul><ul><li>Poor wound healing and development of new pressure ulcers </li></ul></ul><ul><ul><li>Infection...
Factors Involved <ul><li>Older adults are at increased risk for malnutrition due to dietary, economic, psychosocial and ph...
Physiological Factors <ul><li>Chronic illnesses </li></ul><ul><li>Medications </li></ul><ul><li>Poor oral health </li></ul...
Screening and Assessment <ul><li>Assessments should include </li></ul><ul><ul><li>Baseline- nutritional patterns, abilitie...
Screening and Assessment <ul><li>Both current weight and weight history are important!! </li></ul><ul><ul><li>Loss of 10 l...
Screening and Assessment <ul><li>Calorie counts </li></ul><ul><li>Less than 50% eaten document and act! </li></ul>
Screening and Assessment <ul><li>Inconsistencies between reported diet and what you see physically (may indicate poverty o...
Dehydration <ul><li>Quickly becomes a critical problem during periods of illness and is often a primary or secondary reaso...
Dehydration <ul><li>Elderly may present differently than younger people, symptoms can be subtle: </li></ul><ul><ul><li>Irr...
Dehydration <ul><li>Poor skin turgor, dry mouth and lips, subtle change in baseline: families may report  “Mom doesn’t see...
Dehydration <ul><li>Check Orthostatics.  A fall in blood pressure of 20MM HG systolic (when going from lying to standing) ...
Dehydration <ul><li>Lab tests:  serum sodium (hypo or hypernatremia), potassium (hyperkalemia), creatinine (not as reliabl...
Dehydration <ul><li>Alleviate dry mouth: </li></ul><ul><ul><li>Avoid caffeine </li></ul></ul><ul><ul><li>Avoid dry, bulky,...
Be Proactive <ul><li>Improve oral intake: </li></ul><ul><ul><li>Mealtime checks </li></ul></ul><ul><ul><li>Encourage famil...
Be Proactive <ul><li>Cues and Gestures </li></ul><ul><ul><li>Hand over older person’s hand </li></ul></ul><ul><ul><li>Pant...
Be Proactive <ul><li>Difficulty in swallowing referred to SLP. </li></ul><ul><li>Dysphagia occurs in advancing dementia an...
What Do You Think? <ul><li>Which of these situations is an example of nosocomial malnutrition? </li></ul><ul><li>Decreased...
What Do You Think? <ul><li>Malnutrition in a hospital usually refers to </li></ul><ul><li>Carbohydrate- fat intake </li></...
What Do You Think? <ul><li>A patient who fails to consume adequate calories and protein is at increased risk for which of ...
What Do You Think? <ul><li>A patient who develops hypoalbuminemia related to protein deficiency should be monitored for to...
What Do You Think? <ul><li>Which of these approaches would you use with a patient whose appetite deteriorates throughout t...
Discharge Planning Collaboration is key
Goals of Session <ul><li>Clarify Myths and Facts </li></ul><ul><li>Purpose of D/C Planning  </li></ul><ul><li>High Risk Tr...
Myths and Facts <ul><li>1. Only the elderly patient need D/C Planning. T__F__ </li></ul><ul><li>2. The MD must order D/C P...
History of Discharge Planning based on Regulatory Influences <ul><li>HCFA  ( Health Care Financing Admin.) </li></ul><ul><...
Piedmont Hospital Discharge Planning Policy <ul><li>To promote  continuity of care  and support  patients’ safety  for pos...
High Risk Triggers <ul><li>Patients over 70 years old </li></ul><ul><li>Patients with LOS >7 days </li></ul><ul><li>Chroni...
Standards for Assessments <ul><li>Expected outcome=  Plan for safe discharge  and  avoid inappropriate readmission. </li><...
Resource Management Needs Identified <ul><li>In hospital and community resources options </li></ul><ul><li>Problems that m...
<ul><li>Remember Discharge Planning is a process that we all  must share  and we  need to collaborate  and  communicate   ...
Case # 1 What would you do? <ul><li>86 yr. Old female who was visiting her daughter and was admitted to Hosp. for N/V/Abd ...
Case # 2 How would you handle this? <ul><li>Pt age 75 was found wandering and was admitted for CP, suffered cardiac arrest...
Incontinence <ul><li>Clinical Definition (UI): </li></ul><ul><li>Urine loss of sufficient problem to be perceived as bothe...
Voiding Physiology <ul><li>Cerebral Cortex </li></ul><ul><li>Pontine Micturition Center  </li></ul><ul><li>Micturition ref...
Bladder Differences by Gender <ul><li>Female </li></ul><ul><li>Longitudinal Section </li></ul><ul><li>Male  Male </li></ul...
Most Prevalent Types –  Urinary Incontinence <ul><li>Stress UI: urine loss due to sphincter dysfunction- Prolonged use of ...
Most Prevalent Types –  Urinary Incontinence <ul><li>Reflex UI: a spinal cord lesion, Reflex Arc is maintained (Bladder fi...
Most Prevalent Types –  Urinary Incontinence <ul><li>Total UI: complete loss of sphincter fxn or fistula formation </li></...
Other types of Urinary Incontinence <ul><li>Functional UI: normal voiding patterns & normal bladder function; usually rela...
Reversible Factors of Urinary Incontinence - “DIAPPERS” <ul><li>D –  Delirium </li></ul><ul><li>I –  Infection / Irritants...
Effects of Aging R/T Continence <ul><li>Increased nocturia (1-2x/night >60) </li></ul><ul><li>Bladder fills full at lower ...
Indwelling Foley Catheters  <ul><li>30-40% of HAI </li></ul><ul><li>Risk for UTI 1-2% for a single insertion </li></ul><ul...
Foley Catheters in ED <ul><li>CAUTIs- one of CMS Never Events </li></ul><ul><li>Most effective method to prevent CAUTIs is...
Indications for a Urinary Catheter <ul><li>Critically Ill : Alteration in BP or volume status requiring continuous, accura...
When NOT to use a Catheter? <ul><li>An indwelling urinary catheter is  not  appropriate for nursing convenience or for uri...
ED <ul><li>Gateway for most of our older patients </li></ul><ul><li>Ability to initiate change in practice that will carry...
Definition of a Restraint: <ul><li>A  physical restraint  is any “manual method, physical, or mechanical device, material,...
Patient Rights <ul><li>Every patient has the right to expect…. </li></ul><ul><li>Care that is respectful, high-quality, co...
Negative Consequences of Restraint Use: <ul><li>Physical </li></ul><ul><li>Pressure Ulcers </li></ul><ul><li>Decreased cir...
Restraint Alternatives <ul><li>Before an actual restraint can be used, the regulations require that other ways to handle t...
Alternatives for Patient Interference with Medical Devices <ul><li>Addressing the discomfort associated with the treatment...
Alternatives for Fall Prevention <ul><li>Scheduled toileting individualized to patient’s needs and pattern (may also elimi...
Facilitate the Patient’s Environment <ul><li>Use visual clues such as schedules, calendars and clocks </li></ul><ul><li>La...
Diversion <ul><li>Take the patient’s mind off the situation by diverting his/her attention to something else such as: </li...
Least Restrictive Restraint <ul><li>When alternative methods fail to keep the patient and others safe, use the  LEAST REST...
Restraint Use <ul><li>Each time a restraint is used it must be reported to your supervisor or clinical leadership as soon ...
Important to Remember <ul><li>Always remember that restraints/seclusion are prohibited when used as a means of “coercion, ...
Definition of a Restraint: <ul><li>A  physical restraint  is any “manual method, physical, or mechanical device, material,...
Patient Rights <ul><li>Every patient has the right to expect…. </li></ul><ul><li>Care that is respectful, high-quality, co...
Negative Consequences of Restraint Use: <ul><li>Physical </li></ul><ul><li>Pressure Ulcers </li></ul><ul><li>Decreased cir...
Restraint Alternatives <ul><li>Before an actual restraint can be used, the regulations require that other ways to handle t...
Alternatives for Patient Interference with Medical Devices <ul><li>Addressing the discomfort associated with the treatment...
Alternatives for Fall Prevention <ul><li>Scheduled toileting individualized to patient’s needs and pattern (may also elimi...
Facilitate the Patient’s Environment <ul><li>Use visual clues such as schedules, calendars and clocks </li></ul><ul><li>La...
Diversion <ul><li>Take the patient’s mind off the situation by diverting his/her attention to something else such as: </li...
Least Restrictive Restraint <ul><li>When alternative methods fail to keep the patient and others safe, use the  LEAST REST...
Restraint Use <ul><li>Each time a restraint is used it must be reported to your supervisor or clinical leadership as soon ...
Important to Remember <ul><li>Always remember that restraints/seclusion are prohibited when used as a means of “coercion, ...
Upcoming SlideShare
Loading in …5
×

Day 2 senior healthcare consultant conference

979 views

Published on

The second day of a 2-day class on Geriatric issues for all 4 Piedmont Hospitals funded by a HRSA Comprehensive Geriatric Education Grant.

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
979
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
8
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Normal aging brings about inevitable and irreversible changes. These normal aging changes are partially responsible for the increased risk of developing health-related problems within the elderly population. Prevalent problems experienced by older adults include: Normal aging brings about inevitable and irreversible changes. These normal aging changes are partially responsible for the increased risk of developing health-related problems within the elderly population. Prevalent problems experienced by older adults include:
  • Using consistent review of high risk areas decreases likelihood of missing things
  • Need to know baseline prior to illness
  • Nl aging: Older adults usually have more difficult time falling asleep, have impaired sleep maintenance because of arousals, and more difficulty in returning to sleep once they are awakened during night There is a decrease in stage 3 or 4 “deep sleep” and increase in stage 1 or “light sleep” Older adults are more likely to awaken because of environmental factors such as noise or physiological factors such as pain or nocturia Sleep: what is their baseline sleep apnea- do they snore; , restless leg syndrome, depression, delirium Do they use sleep aid at home?? Has it been ordered sleep protocol
  • Nl aging changes: Early satiation, when miss a meal- don’t play catch up Oral health / care Loss of taste buds, sense smell, thirst sensors Affected by chronic issues as pain, PD, COPD, depression as well as medications and constipation With increased frailty and deconditioning, loss of function follows a predictable pattern, with the ability to feed oneself the last activity of daily living (ADL) to be lost Hospital acquired malnutrition: patient may be kept on downgraded diet when the original problem has resolved. If less than 50% need further intervention/nutrition consult Keeping accurate track of I/Os extremely important as older adults at increased risk for dehydration If intake &lt; 1500 ccs need to intervene
  • New onset incontinence= infection Foley cath only reason for having: Foley Catheters are indicated for: ____Urinary Tract Obstruction ____Gross Hematuria with clots ____Neurogenic bladder with retention ____Urologic surgery or studies ____Sacral decubiti Stage 3-4 ____Hospice, Comfort or Palliative Care Remove ASAP- risk for CAUTI increases 5% each day with dramatic rise at 4 days Cognition: affected by lack of sleep, pain, medications, anxiety Screen as snapshot and to identify if need further evaluation Cannot screen for dementia or depression if delirium present; if have undertx or untx depression can not clearly eval for dementia
  • Ortho can be early indicator of higher fall risk, dehydration Often overstate their abilities; if can do task but takes long time or barely able – very close to losing ability Verify with family or facilities Intervention- for pt or work with family- consult rehab Pressure ulcers are associated with complications including cellulitis, osteomyelitis, sepsis, increased length of stay, financial and emotional costs Easier to prevent than heal; “Never event” for CMS
  • Nurses rely on signs and symptoms from patients to direct their care. Older adults respond differently to illness, treatments and interventions due to : changes in organ systems Progressive loss of reserve Interaction of multiple conditions with the acute illness
  • Treatment and interventions will be more accurate Earlier intervention prevents progression to more serious situation Prevent common complications and issues for older patients We will look at changes is S&amp;S with older adults in general and then specifically with cardiac and infections you are most likely to see in the hospital.
  • Must compare to normal prior to the illness Differentiate between normal aging and illness in signs and symptoms Set of symptoms see in older adults that should raise red flags
  • Older adults have the most variability than any other age group. Perception of older adult may not reflect true abilities situation; verify with family, caregivers, facility staff, etc Frail older adults are most likely to have atypical presentation of illness- their reserves are stressed to the max- Add to this normal aging-
  • Symptoms reported become less specific- that is what the older adults is experiencing- usually due to aging changes indifferent organ systems. Discomfort may become a generalized area rather than a limited spot which more clearly defines which organs are involved The different components to respond are muted or dampened with injury or illness thus symptoms reported and signs we look for will be less Ex: immune system, T cells The sensors and alarms systems in body take longer to marshal a response thus pt will have been ill longer before it is recognized- allows greater load of bacteria or virus, or illness process will be further along This leads us to how do problems present -
  • Cognition: less sharp in processing, impaired thinking, all the way to “confusion” Mobility: older adults presenting with New onset falls, weakness impairing daily activities needs to be evaluated for an underlying problem- not just checked for apparent physical injury Decreased appetite, lethargy, self care can be present with any number of medically treatable conditions Let’s look at infections and cardiac issues you will come in contact with in hospital.
  • These issues can be community acquired and result in hospitalization or be acquired during a hospital stay. Looking at the symptoms the patient may be reporting, then the signs you would assess for, and then any labs you might anticipate abnormals in with a younger pt
  • Not all older pt have abd discomfort- they may attribute to bowl issues Decline in sense of smell- they might not have noted this at home Pt may not have reported because they assume incontinence is just part of getting older Thinking- here need baseline and comparison by someone other than pt Temp of 100 can be fever if base temp 97 Blood WBC can be nl – by time see left shift in differential have serious infection; may have dehydration in lab due to decrease intake with incontinence and kidney unable to conserve water (aging); Less T cells to respond and less aggressive and slower to present- temp remains lower thus does not provide help in killing off bacteria/virus as temp at 101 does
  • Not all older pt have abd discomfort- they may attribute to bowl issues Decline in sense of smell- they might not have noted this at home Pt may not have reported because they assume incontinence is just part of getting older Thinking- here need baseline and comparison by someone other than pt Temp of 100 can be fever if base temp 97 Blood WBC can be nl – by time see left shift in differential have serious infection; may have dehydration in lab due to decrease intake with incontinence and kidney unable to conserve water (aging); Less T cells to respond and less aggressive and slower to present- temp remains lower thus does not provide help in killing off bacteria/virus as temp at 101 does
  • Dehydration makes lungs dry- thus no mucus moving- no cough; May not report this is their nl lifestyle does not have any exertion Nl resp rate 14-16 Falls- no clear explanation but depleted reserves Need baseline and a someone to compare- not sure if due to decreased O2 or stressed reserves chest Xray may not be definitive until hydrated
  • Dehydration makes lungs dry- thus no mucus moving- no cough; May not report this is their nl lifestyle does not have any exertion Nl resp rate 14-16 Falls- no clear explanation but depleted reserves Need baseline and a someone to compare- not sure if due to decreased O2 or stressed reserves chest Xray may not be definitive until hydrated
  • Depending on site: May have peripheral neuropathy, some states pain reception declines as age comes from immune systems response with WBC and increased blood flow to area- all decline with aging Lab: same as with other infections
  • These are fairly common cardiovascular issues older adults can present with or acquire while hospitalized. We can cause heart failure with too rapid infusion of IV fluids Stress of hospitalization Being too immobile can result in DVT which can lead to PE
  • Lifestyle may include little exertion so would not c/o this May already sleep on elevated pillows or recliner for other reasons Rales may be masked by co-existing lung disease Rales can be caused by reclining posture- basilar rales is a sign of ventricular failure Need baseline and someone to compare Not too different but sloe to show elevations
  • Pain often isolated to throat, or shoulder or abdomen, or “silent MI” Dyspnea is most common symptom; need baseline, someone to compare; confusion with decreased O2 to brain Slow to elevate; may not elevate high enough to confirm in some malnourished patients
  • 50% of pts with proximal DVT will have asymptomatic PE presentation RARELY hempoptysis Leg edema, discomfort, erythema, warmth Positive D dimer also found in recent surgery, malignancy, trauma, active CV disease ABG can be normal or reveal resp alkalosis due to hyperventilation You can see how the symptoms are vague, overlapping, - not clear cut but are not normal signs for older patients. Try this quick case with an older patient
  • Progressive issues with strength, mobility over short period of time: had falls Some baseline
  • The report you receive does not have any major definitive problems. Let’s look at the symptoms, signs and lab
  • Symptoms indicate a major change that has not improved Temp and resp that could be important – need to know baseline if possible; but know that 20 is higher than expected; temp could indicate a fever From what we have looked at today; could this be heart failure, MI, UTI? Or a combination of these and others such as depression.
  • Recognize the significance of atypical symptoms / presentations and pursue possible causes- may be more than one medical issue involved By recognizing that older adults can have atypical presentations, Nurses can ensure quality care and positive outcomes.
  • Older patients are at high risk for complication of delirium which can require increased nsg time and staff as well as increased LOS, NH placement, morbidity, mortality, fall risk, infection, aspiration, malnutrition- dehydration Delirium is a frequent complication of illness and hospitalization for older adults- up to 80 %, and up to 89% of pts with delirium. But it’s effects can be largely or completely reversed when cause is identified and treated Nurses are the primary professionals to detect delirium in patients and prevent these complications. We are going to look at specifics of delirium, how to assess and prevent this and appropriate interventions when it occurs.
  • Delirium is a disorder of multiple factors 1. normal aging, there is less physiological reserve with the brain being more susceptible; the balance is more fragile 2. changes in environment- such as hospitalization, ICU stay -74% of all cases occur in critical care areas), terms such as ICU psychosis imply an expected outcome; or move to NH 3. Leading cause of delirium is Adverse drug reactions- always think drugs 4. Malnutrition ( can have on admission or may cause during stay), anything that alters cerebral blood flow ( CVA, head injury, blood loss); decreased O to brain ( shock, heart Failure, anemia); fluid, lyte imbalance- dehydration, hypo or hyper natremia); vit deficiency, infections, metabolic disorders( DM, hypercalcemia, liver failure); Withdrawal- alcohol, narcotics, barbiturates, SSRIs Under treated pain 5. Surgery-up to 60% of older surgical pts have delirium with hip fx,vascualr surgery and elective joints have highest incidence, use of versed increases risk ( hyperactive most commonly seen) as does epidural anesthesia and longer duration of anesthesia Can begin with transient restlessness in the immediate post op period- leads us to assessment for delirium but there are 3 types of delirium presentation
  • agitated, aggressive, hallucinations, constant motion, non-purposeful-repetitive movements, verbally and physically aggressive, hallucinations Clouded inattention- requires strong stimulation to arouse; withdrawn, apathy, inattention; Often unrecognized- poorer overall prognosis- most common in older adults fluctuates unpredictably Behaviors you see demonstrated vary somewhat depending on type of delirium; Generally see trying to escape the environment, removing medical equipment, maybe combative, non purposeful repetitive movements, moaning- calling out, resistive to care Delirium develops over hours- days Lasts days to months First symptom is often anxiety ATTENTION night staff- 1-3 days prior to full blown delirium see change in sleep-wake cycle or disturbed sleep, restless, anxious, irritable, loss of mental clarity or some disorientation, change in ability to shift or change focus
  • Watch labs, record I&amp;O and food intake; encourage 1500 ml as minimum; check orthostatic BP OOB, eat in chair, ambulate 3x/day; obtain PT referral as needed Clocks, calendars, white boards; Therapeutic Rec for engagement orient and engage Begin sleep protocol ( warm drink, back rub, oral care and warm washcloth- turn on music, turn down lights, consolidate staff trips, decrease noise in hallway Glasses, hearing aids- working battery, wears glasses, telephone aids from hospital operator Assessment requires a way that different nurses can compare their findings as well as comparing a patient’s behaviors over time.
  • Prior to illness- caregiver, facility staff, family, friends Baseline Memory- short term, and processing , completing tasks Alertness is basic arousal, attentiveness = thoughtful engagement with environment; select what want out of environment, sustain focus to process information- without this have safety risk Function- independent, or requires assistance Mobility Now need to compare to current status-
  • Is this their baseline mental status or has pt had any fluctuations in mental status in past 24 hrs as evidenced by fluctuation on sedation scale, GCS, or previous delirium assessment
  • First establish that pt can follow a simple “yes” “no” – such as nod head, squeeze hand- if can do this then conclude there is the basic ability to understand directions Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? 2.Letters: Say to patient “ I am going to read you a series of 10 letters. Whenever you hear the letter A, indicate by squeezing my hand” Then read letters in normal tone Score this a incorrect if they squeeze on any letter other than A, or do not squeeze when you say A OR can use pictures- most commonly used in ICUs or CCUs . Show 5 pictures 3 sec each. Then tell them going to show them more pictures and to squeeze or indicate when they see a picture from the first set
  • First establish that pt can follow a simple “yes” “no” – such as nod head, squeeze hand- if can do this then conclude there is the basic ability to understand directions Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? 2.Letters: Say to patient “ I am going to read you a series of 10 letters. Whenever you hear the letter A, indicate by squeezing my hand” Then read letters in normal tone Score this a incorrect if they squeeze on any letter other than A, or do not squeeze when you say A OR can use pictures- most commonly used in ICUs or CCUs . Show 5 pictures 3 sec each. Then tell them going to show them more pictures and to squeeze or indicate when they see a picture from the first set
  • If pt is not positive on BOTH 1 and 2 then stop. Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Use these questions Command Say to pt “Hold up this many fingers ( hold up 2 fingers in front of pt. “Now do same thing with the other hand ( not repeating the number of fingers) This helps affirm that pt did not randomly guess correctly the 4 questions
  • Score 1&amp;2 and either 3 or 4 = for delirium. Alert ( normal) Vigilant ( hyperalert) Stupor (difficult to arouse) Coma (unarousable)
  • Look at handout / worksheet in folder- looks very busy because have put all the info on one page. Do not be overwhelmed- just 4 questions CAM was designed to be scored based on observations made during brief but formal cognitive testing. There is a false positive rate of 10%. The tool identifies the presence or absence of delirium but does not assess the severity of the condition Now that you have a tool, How frequently do you assess for delirium?
  • On admission to get current status Daily so can compare if changes When see potential subtle changes in behavior to determine what your actions need to be In order for this info to be useful, it must be documented for other staff to com pare to.
  • To compare need to record baseline prior to illness, the score from the CAM and specific behaviors noted
  • Collaborate with MDs re: possible untreated infection( often UTI or resp), lab work,; MDs and pharmacists for a med review and evaluate for interactions ( lasix, lanoxin, theophyllin)
  • Family Have them bring familiar items ( pictures, play favorite music; determine if they are a source of support-ask them to stay; educate family delirium is a temporary condition that will improve with tx It is reasonable and appropriate to ask family to help- similar to a parent staying with a frightened hospitalized child !
  • Remove unnecessary equipment Avoid physical and chemical restraints; foley catheters and IV are one point restraints Only 4 reasons for foley cath: oveflow with obstruction, fl balance is critical, short term for stage 3 or 4 ulcer, severely impaired or terminally ill 80% hosp acquired UTI from foley and 40% of ALL UTI due to foleys Staff continuity- approach in calm manner and voice; use simple terms, avoid sudden movements Calm approach / reassure
  • Proactively address- nutrition, hydration, skin breakdown, blood clots ( immobility), mobility and deconditioning / loss of function, use sensory aids,
  • Baseline- essential On adm and daily: miss the hypoactive ones- we have hours to days to pick up on it building Prevention easier than treating It is obvious when you look the type and length of contact we have with our patients that nurses were found to be superior when compared to physicians in detecting delirium. You are the best group positioned to prevent the medical complications for the pts and therefore the increased stress on nsg staff.
  • Under diagnosed because symptoms may be confused with the effects of illness or medications. These could be our frequent fliers who complain of multiple physical ailments. Depression can amplify these. Depression is NOT a normal part of aging.
  • Explaining depression to someone who has not experienced it is hard. For those of you who experience severe PMS…..imagine feeling like that ALL THE TIME.
  • Usually a decrease in appetite/ daytime sleepiness and fatigue, insomnia, awakenings./memory loss, difficulty concentrating, abnormal thoughts, excessive guilt, thoughts of death and suicide. Different people can present with different symptoms. Some are overtly sad. Others…just angry. OR Apathy...they just don’t care anymore.
  • Overlapping symptoms: Fatigue, psychomotor slowing, loss of appetite, sleep disturbances, etc. Often in clinical setting physician doesn’t have time to address anything except physical complaints. Because of the Stigma associated with mental illness many patients will deny feelings of depression.
  • Women higher prevalence, but white males over the age of 80 have higher rates of suicide. It may not be that women are MORE depressed. It may be the way they show it. Men are less likely to present with overt sadness or crying the way women do. Men more likely to present with anger, irritability, emotional withdrawl or substance abuse. I don’t think older men are any less depressed it is just the way they show it.
  • I am a firm believer that what it boils down to is a chemical imbalance of the neurotransmitters that control mood. serotonin, dopamine and norepinephrine. And there are many things that can throw these out of whack. You’ve heard people say “get over it. It’s all in your head” Well…….yeah. And you can’t just ‘Get over it’. Alcohol and drug abuse used to be considered only a symptom of underlying depression. New studies have shown that it can actually be a cause. Think about it…you’ve all seen the commercials…’here’s you brain on drugs’? What initially may produce euphoria, with continued use could alter brain chemistry causing depression.. The synapses get fried. Alcohol by definition is a depressant. So the depressed person who turns to alcohol to improve their mood is not doing themselves any favors. Heredity plays less of a role in late life onset of depression. Usually, familial depression presents earlier in life and is more chronic in nature. Medications: Illnesses:
  • This makes sense. These diseases are associated with vascular ischemia. For instance, diabetics have chronic circulation issues resulting in kidney failure, blindness, amputations. It stands to reason that the cerebrovascular system is affected as well. Limiting the blood supply can cause neurobiological changes in the neurotransmitters responsible for mood.
  • SSRI’s generally the first line of treatment. SNRI – Cymbalta has been associated with fatal liver disease in patients with pre-existing liver disease. DNRI – Wellbutrin less likely to be associated with wt. gain. May be effective for patients who are lethargic. Remeron – is sedating and can cause increased appetite and wt.gain in a high percentage of patients. Tricyclics – Anticholinergic effects such as dry mouth, constipation, urinary retention, tachycardia, confusion, delirium and hallucinations. Elderly particularly susceptible. Can also cause orthostatic hypotension. MAO’s – Way too many interactions.
  • This is the tool we use at Piedmont. Remember this is just a screening tool. It does not diagnose. How you approach a patient with this is important. Don’t just barge into the room and say “please fill this out”. These are personal questions. Get to know your patient first. Develop a relationship. A truly depressed person may not be inclined to tell the truth. If they know you care they may be more straightforward. Ask permission to discuss the tool and then explain why it is important to be honest. Ask them to complete the first 5 questions. If they score more that one on these, ask them to answer all the questions.
  • Primarily talk about malnutrition- where intake is less than your needs
  • We are going to focus on hospitalized older adults: Actually med surg pts nutritional status actually tends to worsen during a hospitalization Just how important is nutrition during a hospital stay?
  • LOS increases by 90% Hospital charges can be as much as 75% higher As it weaken the respiratory muscles – leads to respiratory infections Protein calorie malnutrition, type most often in these pts, results in skeletal muscle wasting- then decreased strength and falls
  • Immune system is affected Also puts at higher risk for emboli If protein drops enough leads to edema in tissue or ascites, diarrhea Affects CO, hr , and BP- all should be monitored closely medications that bind to protein will then have higher levels – thus standard dose can actually be at toxic levels : think dilantin, coumadin
  • You have more specifics on these in your handout so I am going to focus on the physiological factors particularly as they would affect a hospital patient
  • Chronic issues such as cardiac and COPD increase the calorie requirements due to increased muscles required for basic function Medications- alter taste, absorption, appetite Last 3 items refer to normal aging changes that affect food intake Decreased lean muscle ( skeletal) and increased percent of fat When have protein calorie malnutrition- breakdown skeletal muscle then loss of strength which causes decraesed physical activity- vicious cycl Others are early satiety ( feel full with less eaten) ,overgrowth of bacteria in bowel prevents absorption of nutrients Disease/ symptoms that affect nutrition: N/V/D, anxiety, pain, fatigue, depression, SOB, neuro conditions affect chewing-swallowing Surgery- injury-burns all increase nutritional needs significantly Then add in NOSOCOMIAL causes: hospital acquired being in hospital – meals held due to tests and not replaced; long periods of NPO due to concurrent tests scheduled; diets not advanced; intake not observed; Data shows Older adults don’t “play catchup” when they miss intake and have wt loss Mismanagement/inattention: MD writes order- dietitian dev plan- nurse records intake Who’s job is it to evaluate nutritional interventions for effectiveness; take a “wait and see” attitude for improvement- this gets our older pts in trouble
  • Need to know baseline so can evaluate where and what are needs, issues- goes toward the discharge plan
  • Need accurate info for med calculations and determine nutritional needs Measure do not use pt/family reports
  • Use calorie cts for accurate estimate of calorie and nutrient intake However- if less than 50% eaten off tray- this is a red flag- intervene; NPO for more than a few hours should also raise your concern
  • Can also indicate self neglect, cognitive impairment Fluid intake is related to food intake: if not eating enough then almost sure they are not drinking adequately
  • Why is this more a problem with older pts? Mortality of up to 50% if not treated Risks: Nl aging shift in body composition- have a decrease in total fluid thus less to lose before get in trouble plus kidneys become less able to concentrate urine Meds- diuretics Illnesses v/d Chronic issues- incontinence- they will restrict intake to decrease this!!!!!!!!! Being in hospital- functional problem of getting to fluids , selection
  • Makes early dx difficult symptoms vague, deceptive, absent
  • Look for tongue and mucus membrane dryness as well as longitudinal furrows, speech difficluties, CONFUSION or may be a decline in sharpness
  • Particularly if they are symptomatic;c /o dizziness with rising very telling
  • 3 types of dehydration- one easiest to recognize with labs- hypertonic ( water deficit) Na &gt; 150, serum osmolality &gt;300 Water and electrolyte deficiency= isotonic Hypotonic- loss of lytes greater than loss of waqter
  • Symptomatic interventions- after if has occurred Easier to address hydration ad nutrition than it is to correct malnutrition and dehydration: proactive is best
  • Food intake less than 50% at a meal – don’t wait, intervene; liberalize diet- better to eat something than little or nothing; nutrient dense foods NPO for multiple concurrent tests- rearrange to space them so pt can get food and fluids ; if npo for extended time be sure they have IV hydration Encourage fluid intake of 1500 ml- don’t wait until IV is out- may actually get it out sooner this way; unless medically contraindicated- chf, renal Involve pt- explain nl aging diminishes thirst “alert” and they need to consciously drink when not thirsty- studies show older pts will try when informed Company during meals- we all eat more when we have this; meals are a social event for most people; family , friends, bring favorite foods as allowed
  • If feeding a patient- when have memory issues- may try mime actions sit across as though at dinner table
  • Silent aspiration Look for repeated swallows to move food, thick or congested voice or coughing while eating Do not provide nutritional supplements WITH meals- use between as with med passes; these are rich and may result in diarrhea so introduce slowly: start with ¼ to ½ can a day for several days then if no change in bowel habits increase to a full can and continue like this
  • 2
  • 4
  • 1
  • 1
  • 2
  • Home with no aftercare needs identified Home Health Care; Transportation needs; Financial assistance;Assisted Care/ Personal Care Homes;Nursing Homes ( 2 levels SNF/Subacute or Custodial);LTAC;Rehab facilities Hospice Care ( home or facility); Homeless Shelters; Psych Tx ( Inpatient /OP)
  • Pt returned home with daughter with HH. She was to have Emergency Response System/ Lifeline and HH with increased days for Housekeeper assistance when she returned to her home in Maryland.
  • Pt was drawing prison uniform with Prison ID #. Upon investigation, he had spent past 20 yrs. In Ga State prison System. With Atlanta Police assistance, his family was located in Ala. And he was placed in a Personal Care Home in Ala.
  • When I talk about incontinence, I’m speaking of those individuals that have a significant problem and it has a major affect on their everyday life. For instance, my mother unconsciously crosses her legs when she sneezes so she doesn’t leak. Even though she meets Webster’s definition for incontinence, she has found a way to manage her sphincter weakness and therefore it is not bothersome to her… she does NOT meet the clinical definition of incontinence.
  • Cerebral Cortex – social continence Pontine Micturition Center – automatic coordinated voiding Micturition reflex – threshold Spinal Cord Pathways – communication pathways (sympathetic, parasympathetic, pudenal) Bladder – smooth muscle contracts, norm: low pressure storage with ability to stretch Urethral Sphincter – norm: remain closed during bladder filling &amp; to relax prior to and during voiding “ Head to Tail” assessment
  • Males have 3 advantages over females in remaining continent. These things give greater urethral resistance and are less likely to allow urine to involuntarily pass from the bladder Length of urethra is greater in males Prostate gland in a man gives additional compression at the proximal urethra 2 curves of the urethra in a male So, incontinence is widely seen in females but males do have their own set of problems, usually involving the prostate.
  • Prostatectomy: the sphincter is located just below the prostate. At risk of damaging the sphincter or the nerves that innervate the sphincter muscle. Pelvic Floor Relaxation Prostatectomy Sphincter Denervation ( SCI, Myelomeningocele ) Talk about the use of Urinary catheters later.
  • urine loss due to inappropriate bladder contractions Characterized by frequency and/or urgency Men with enlarged prostates have urinary frequency issues. Need to be worked up by a urologist to determine the true etiology.
  • CORRECT THE CAUSE! Stress – Meds: Sympathomimetic drugs increase the muscle tone in the proximal urethra (Sudafed, Ornade, Dexatrim without Caffeine) OAB - Anticholinergic Meds: raise the sensory threshold and reduce bladder irritability. But, can cause urinary retention
  • Pt with dementia. The brain is not interpreting the signals from the bladder. Lack of orientation or unfamiliar surroundings… Where’s the bathroom? Physically unable to get out of bed or the chair to get to the bathroom… Orthopaedic surgery patients.
  • D: Happens w/ new surroundings, narcotic use given for pain I: Irritants – Caffeine, nicotine, Nutrasweet, alcohol A: Estrogen deficiency can reduce urethral resistance as much as 33%... PINK and PLUMP P: Sedatives, narcotics, muscle relaxants, some anti-hypertensives, anitdiarrheals, antipsychotics, antidepressants, diuretics P: severe depression can reduce a person’s motivation to stay dry… DULOXETINE (not FDA approved) E: Polyuria with Diabetes R: Our ortho patients can’t get to the BR S: #1! When stool stays in the colon, it takes up space and can shift or irritate the urinary structures enough to create incontinence.
  • Having a urinary catheter means the door is always open for infection Use of silver catheters (antimicrobial) D/C them ASAP Every time the closed system is opened (draining the BSB, flushing the catheter, taking a culture) microorganisms are introduced to the urinary tract Rather do in &amp; out cath, b/c the doorway to the bladder stays closed
  • Day 2 senior healthcare consultant conference

    1. 1. Dee Tucker RN, MS, GCNS-BC Nursing Service An Overall Assessment Tool of Older Adults SPICES
    2. 2. SPICES <ul><li>Use as a screen for the most frequently occurring health problems in hospitalized older adults </li></ul>
    3. 3. SPICES <ul><li>Screen daily. </li></ul><ul><li>Follow up with further assessment. </li></ul><ul><li>Initiate preventive and therapeutic interventions. </li></ul><ul><li>Prevent hospital-acquired complications! </li></ul>
    4. 4. SPICES Interventions Assessment S leep Disorders P roblems with Eating/Feeding, P ain I ncontinence C ognition E vidence of Falls, Mobility problems S kin Breakdown
    5. 5. SPICES Interventions Assessment S leep Disorders Restless or wake-sleep cycle disturbance Sleep protocol Evaluate for cause & treat (pain, delirium, etc)
    6. 6. SPICES Interventions Assessment P roblems with Eating/ Feeding, P ain % food eaten for each meal last 24hr PO fluid intake amount UOP Wt if daily LBM If less than 50% If less than 1.5 to 2 Liters; or NPO, or clear liquid diet for 24 hrs or more If less than 30 ml/hr If gain 1-2 Kg in 24 hrs If no BM in 3 days
    7. 7. SPICES Interventions Assessment I ncontinence Any episode Foley catheter Begin Toileting schedule Evaluate for UTI DC’ing when C ognition Any change in LOC, attentiveness, memory, Evaluate for cause (pain, delirium, etc
    8. 8. SPICES Interventions Assessment E vidence of Falls, Mobility problems Orthostatic BP & pulse Function & mobility as observed in last 24 hrs Falls- circumstances If greater than 20 point drop in systolic If below baseline, or declining If occur S kin Breakdown Any change With risk or actual impairment
    9. 9. SPICES <ul><li>Questions? </li></ul><ul><li>Tell me what you’ve learned. </li></ul><ul><li>Thank You </li></ul>
    10. 10. Atypical Disease Presentation in Older Adults Dee Tucker, MS, RN, GCNS-BC Nursing Administration
    11. 11. Atypical Disease Presentation <ul><li>By assessing older patients for atypical presentations, nurses provide appropriate interventions and prevent complications / crises. </li></ul>
    12. 12. Signs and Symptoms Learn baseline prior to illness Remember aging changes Recognize presenting symptoms
    13. 13. Baseline prior to illness <ul><li>Variability </li></ul><ul><li>Verify </li></ul><ul><li>Frailty </li></ul>
    14. 14. Aging Effect <ul><li>Non specific </li></ul><ul><li>Less acute </li></ul><ul><li>Slow to present </li></ul>
    15. 15. Presenting Symptoms Signs and symptoms in older patients are generalized and can represent any number of medical situations.
    16. 16. Atypical Disease Presentation <ul><li>Infections </li></ul>Urinary Tract Respiratory Skin
    17. 17. UTI The older kidney has less concentrated urine. <ul><li>Kidneys do not conserve water as well </li></ul><ul><li>Increased amount of drugs in blood </li></ul>
    18. 18. UTI <ul><li>Symptoms </li></ul><ul><li>tired, poor appetite, perhaps abdominal discomfort, perhaps foul smell to urine </li></ul><ul><li>Signs </li></ul><ul><li>incontinence, trips/fall, less sharp thinking, perhaps temperature </li></ul><ul><li>Lab </li></ul><ul><li>urine- WBC, bacteria; perhaps WBCs elevated in blood work </li></ul>
    19. 19. Respiratory Infection BLUE represents amount of air inhaled RED represents lungs PINK represents the diaphragm
    20. 20. Respiratory Infection <ul><li>Symptoms </li></ul><ul><li>tired, poor appetite, perhaps cough, perhaps shortness of breathe </li></ul><ul><li>Signs </li></ul><ul><li>respiratory rate, tripping/fall, perhaps temperature; less sharp thinking </li></ul><ul><li>Lab </li></ul><ul><li>WBC ?, cxr ?, </li></ul>
    21. 21. Skin Infection <ul><li>Symptoms </li></ul><ul><li>tired, some tenderness </li></ul><ul><li>Signs </li></ul><ul><li>increased color, maybe swelling, drainage </li></ul><ul><li>Lab </li></ul><ul><li>blood- ? </li></ul>
    22. 22. Atypical Disease Presentation <ul><li>Cardiac Issues </li></ul>Heart Failure with pulmonary edema Myocardial Infarction Pulmonary Embolism
    23. 23. Heart Failure with Pulmonary Edema <ul><li>Symptoms </li></ul><ul><li>tired, poor appetite, perhaps shortness of breathe or leg swelling </li></ul><ul><li>Signs </li></ul><ul><li>perhaps rales; less sharp </li></ul><ul><li>thinking </li></ul><ul><li>Lab </li></ul>
    24. 24. Myocardial Infarction <ul><li>Symptoms </li></ul><ul><li>fatigue, weak, restless, shortness of breath, perhaps pain </li></ul><ul><li>Signs </li></ul><ul><li>perhaps syncope, less mental sharpness, perhaps confusion </li></ul><ul><li>Lab </li></ul><ul><li>cardiac enzymes </li></ul>
    25. 25. Pulmonary Emboli <ul><li>Symptoms: perhaps chest pain with inspiration, perhaps shortness of breath </li></ul><ul><li>Signs: elevated HR, tachypnea, rales; perhaps LE symptoms of DVT, dyspnea </li></ul><ul><li>Lab: positive D-dimer; perhaps ABGs changes </li></ul>
    26. 26. Case <ul><li>86 yo man is admitted for c/o progressive weakness and fatigue: unable to carry out his normal daily activities, 2 falls. </li></ul><ul><li>He lives with his wife in their home. He was independent in all ADL’s and IADLs. He enjoyed his garden daily and worked part time at a real estate office. </li></ul>
    27. 27. Case <ul><li>He is cooperative, pleasant and looks quite well. No history of dyspnea or coughing. He has an IV going and waiting for more lab tests. He requires assistance to get to the bathroom. </li></ul><ul><li>Report from night shift: he has bilateral basilar rales; temp 99.2, Resp 20; BP unchanged; remains weak; up to bathroom numerous times; no complaints of pain but did not sleep well and is restless </li></ul>
    28. 28. Symptom Presentation in Older Adults <ul><li>Baseline: independent ADLs, IADLs, very active self sufficient; no dyspnea or cough </li></ul><ul><li>Symptoms </li></ul><ul><li>fatigue, unable to do ADLs, requires assistance to ambulate to BR </li></ul><ul><li>Signs </li></ul><ul><li>restless, bilateral basilar rales, little sleep; Temp 99.2; resp 20 </li></ul><ul><li>Lab: none available </li></ul>
    29. 29. Clinical Pearls <ul><li>Symptoms: vague, less acute, slow to present </li></ul><ul><li>Compare to normal baseline </li></ul><ul><li>Assess for potential causes </li></ul>
    30. 30. Delirium: Can You Recognize Acute Confusion? Dee Tucker, MS, RN, GCNS-BC Nursing Administration
    31. 31. Delirium: Risk <ul><li>Normal Aging Changes </li></ul><ul><li>Environment </li></ul><ul><li>Medications </li></ul><ul><li>Medical conditions </li></ul><ul><li>Procedures </li></ul>
    32. 32. 3 Types of Delirium <ul><li>Hyperalert, hyperactive </li></ul><ul><li>Hypoactive, hypoalert </li></ul><ul><li>Mixed </li></ul>
    33. 33. Prevention <ul><li>Ensure hydration and nutrition </li></ul><ul><li>Mobilize </li></ul><ul><li>Support Cognition </li></ul><ul><li>Enhance sleep </li></ul><ul><li>Use sensory aids </li></ul>
    34. 34. Assessment <ul><li>Baseline </li></ul><ul><li>Cognition </li></ul><ul><li>Function </li></ul><ul><li>Mobility </li></ul>
    35. 35. Assessment for Delirium <ul><li>CAM Confusion Assessment Method </li></ul><ul><li>Acute onset; fluctuating </li></ul><ul><li>Inattentive </li></ul><ul><li>Disorganized thinking </li></ul><ul><li>ALOC </li></ul><ul><li>Delirium = 1 & 2 are present with either #3 or #4 </li></ul>
    36. 36. CAM <ul><li>1 st Sudden Onset </li></ul><ul><li>After admission </li></ul><ul><li>Prior to admission </li></ul><ul><li>If present, go on to #2 </li></ul>
    37. 37. CAM <ul><li>2 nd Inattention </li></ul><ul><li>Tests of attention </li></ul><ul><ul><li>Count backwards from 20. </li></ul></ul><ul><ul><li>State days of week forward & backward </li></ul></ul><ul><ul><li>Alternatives for patients who can not speak </li></ul></ul><ul><ul><li>If present, go on to #3 </li></ul></ul>
    38. 38. CAM <ul><li>3 rd Disorganized Thinking </li></ul><ul><li>Clinical evaluation of conversation </li></ul><ul><li>Sets of Questions </li></ul><ul><li>Present or not, go on to # 4 </li></ul>
    39. 39. CAM <ul><li>4 th Altered Level of Consciousness </li></ul><ul><li>Anything other than alert = positive </li></ul><ul><li>Hyperalert </li></ul><ul><li>Lethargic </li></ul><ul><li>Stuporous, comatose </li></ul>
    40. 40. CAM <ul><li>CAM Confusion Assessment Method </li></ul><ul><li>Acute onset; fluctuating </li></ul><ul><li>Inattentive </li></ul><ul><li>Disorganized thinking </li></ul><ul><li>ALOC </li></ul><ul><li>Delirium = 1 & 2 are present with either #3 or #4 </li></ul>
    41. 41. Assessment Frequency <ul><li>Admission </li></ul><ul><li>Daily </li></ul><ul><li>With behaviors changes </li></ul>
    42. 42. Documenting <ul><li>Specific behaviors -Avoid general terms i.e. confusion, disoriented </li></ul><ul><li>Alert vs attentive </li></ul><ul><li>Never Event- will be one </li></ul><ul><li>Geriatric Tools and Assessment : enter under “Documents” </li></ul>
    43. 43. Interventions with Delirium <ul><li>Collaboration </li></ul><ul><li>Safe environment </li></ul><ul><li>Prevent complications </li></ul>
    44. 44. Interventions with Delirium <ul><li>Collaboration </li></ul><ul><li>Ask pharmacist to review meds </li></ul><ul><li>Check labs </li></ul><ul><li>Notify MD / share what done and think </li></ul><ul><li>Educate family </li></ul>
    45. 45. Interventions with Delirium <ul><li>Safe Environment </li></ul><ul><li>Orient frequently, Reassure, family Room near nurses station, quiet </li></ul><ul><li>Minimize equipment </li></ul><ul><li>Avoid restraints- includes IV, foley </li></ul><ul><li>Continuity- routine, staff </li></ul><ul><li>Sensory aids </li></ul>
    46. 46. Interventions with Delirium <ul><li>Prevent Complications </li></ul><ul><li>Hydration/ Fluid balance </li></ul><ul><li>Nutrition </li></ul><ul><li>Deconditioning </li></ul><ul><li>Pain management </li></ul><ul><li>Monitor O2, CV function </li></ul><ul><li>Enhance sleep </li></ul>
    47. 47. What Do You Think? <ul><li>1. Nurses must learn to recognize signs of delirium in older adults because: </li></ul><ul><ul><li>a. It is an indication of the progression of chronic illness. </li></ul></ul><ul><ul><li>b. It is a indication of serious illness that needs to be evaluated promptly. </li></ul></ul><ul><ul><li>c. It is common but insignificant finding which does not require medical evaluation. </li></ul></ul><ul><ul><li>d. If nurses recognize it, then physicians will not be called so often </li></ul></ul>
    48. 48. What Do You Think? <ul><li>2. The following are possible precipitating causes of delirium in elders: </li></ul><ul><ul><li>a. A urinary tract infection. </li></ul></ul><ul><ul><li>b. Adverse reaction to a drug. </li></ul></ul><ul><ul><li>c. Dehydration. </li></ul></ul><ul><ul><li>d. All of the above. </li></ul></ul>
    49. 49. What Do You Think? <ul><li>3. Patients with dementia are at increased risk for developing delirium. </li></ul><ul><ul><li>a. False </li></ul></ul><ul><ul><li>b. True </li></ul></ul>
    50. 50. What Do You Think? <ul><li>4. What is the cardinal sign of delirium? </li></ul><ul><ul><li>a. Change in baseline cognition and function within hours or days. </li></ul></ul><ul><ul><li>b. Inability to remember recent events. </li></ul></ul><ul><ul><li>c. Forgetting an appointment. </li></ul></ul><ul><ul><li>d. Answering &quot;I don't know&quot; frequently on the Mini-Mental Status Exam. </li></ul></ul>
    51. 51. What Do You Think? <ul><li>5. Which of the following predisposes older adults to delirium? </li></ul><ul><ul><li>a. Cognitive impairment </li></ul></ul><ul><ul><li>b. Sensory losses </li></ul></ul><ul><ul><li>c. Severe illness </li></ul></ul><ul><ul><li>d. Dehydration </li></ul></ul><ul><ul><li>e. All of the above </li></ul></ul>
    52. 52. Delirium <ul><li>ALL older patients at risk </li></ul><ul><li>Baseline prior to illness </li></ul><ul><li>Use CAM </li></ul><ul><li>Prevention / Intervention </li></ul>
    53. 53. Depression
    54. 54. Incidence <ul><li>60 million Americans greater than 65 yrs. </li></ul><ul><li>Only 10% of these receive treatment </li></ul><ul><li>Major public health problem – leading to impaired functional status, increased mortality, and excessive use of healthcare resources. </li></ul>
    55. 55. Definition <ul><li>Clinical syndrome characterized by lower mood tone, difficulty thinking, and somatic changes precipitated by feelings of loss and / or guilt. </li></ul>
    56. 56. Symptoms of Depression <ul><li>Feeling of worthlessness or sadness </li></ul><ul><li>Loss of interest or pleasure in activities previously enjoyed </li></ul><ul><li>Loss of energy - fatigue </li></ul><ul><li>Irritability, agitation </li></ul><ul><li>Change in appetite </li></ul><ul><li>Sleep problems </li></ul><ul><li>Cognition difficulties </li></ul><ul><li>Suicidal ideation </li></ul>
    57. 57. Diagnosis Challenges <ul><li>Concurrent medical illness with overlapping symptoms of depression </li></ul><ul><li>Medication side effects </li></ul><ul><li>Impaired communication in the elderly </li></ul><ul><li>Multiple somatic complaints </li></ul><ul><li>Focus on complex medical issues </li></ul><ul><li>Stigma </li></ul>
    58. 58. Risk Factors <ul><li>Female sex </li></ul><ul><li>Social isolation </li></ul><ul><li>Unemployment or retirement </li></ul><ul><li>Widowed, divorced, or separated </li></ul><ul><li>Serious medical conditions, especially vascular problems </li></ul><ul><li>Uncontrolled pain </li></ul>
    59. 59. Causes of Depression <ul><li>Many different theories, Many different causes </li></ul><ul><li>Brain neurotransmitter imbalance – predominately serotonin and dopamine </li></ul><ul><li>Alcohol and drugs </li></ul><ul><li>Heredity </li></ul><ul><li>Medications </li></ul><ul><li>Illnesses </li></ul>
    60. 60. Vascular Depression <ul><li>Importance of chronic ischemic cerebral changes only recently recognized </li></ul><ul><li>Most prominent in late life depression </li></ul><ul><li>Associated with diseases such as CAD, diabetes, stroke </li></ul>
    61. 61. Pharmacologic Treatment <ul><li>SSRI’s – Celexa, Lexapro, Zoloft, Paxil, Prozac </li></ul><ul><li>SNRI’s – Effexor, Cymbalta </li></ul><ul><li>DNRI’s – Wellbutrin </li></ul><ul><li>Noradrenergic and specific serotonergic – </li></ul><ul><li>Remeron </li></ul><ul><li>Tricyclics – Elavil, Sinequan, Pamelor </li></ul><ul><li>MAO inhibitors – Nardil, Parnate </li></ul>
    62. 62. Other Medication Considerations <ul><li>Start low and go slow </li></ul><ul><li>Explain temporary side effects to encourage compliance </li></ul><ul><li>May not see full therapeutic benefits for several weeks (6-12) </li></ul><ul><li>Assure close monitoring every 1-2 weeks </li></ul><ul><li>Don’t discontinue suddenly </li></ul><ul><li>Monotherapy better in the elderly </li></ul><ul><li>Consider $$COST$$ </li></ul>
    63. 63. Other Forms of Treatment <ul><li>Psychotherapy : individual and/or group </li></ul><ul><li>Problem – Medicare and other insurances offer incomplete coverage (50% allowable) </li></ul><ul><li>Family involvement (unless they are the problem) </li></ul><ul><li>Church or community involvement </li></ul><ul><li>ECT </li></ul>
    64. 64. What can we do ? <ul><li>Screening </li></ul><ul><li>SPICES </li></ul><ul><li>Enhance physical function and social support </li></ul><ul><li>Encourage daily participation in therapies </li></ul><ul><li>Rec. Therapy consult </li></ul><ul><li>Assist with problem solving </li></ul><ul><li>Provide emotional support </li></ul>
    65. 66. “ SIG-E-CAPS” <ul><li>Acronym for evaluating patient’s progress </li></ul><ul><li>S Sleep disturbances </li></ul><ul><li>I Interest in activities </li></ul><ul><li>G Guilt and/or low self esteem </li></ul><ul><li>E Energy </li></ul><ul><li>C Concentration </li></ul><ul><li>A Appetite changes </li></ul><ul><li>P Psychomotor changes (agitation/retardation) </li></ul><ul><li>S Suicide </li></ul>
    66. 68. Nutrition and Hydration in the Older Adult
    67. 69. Definitions <ul><li>Malnutrition : any disorder of nutrition status, including disorders resulting from inadequate intake (not getting enough in), improper metabolism, or over-nutrition (eating too much!). </li></ul>
    68. 70. Demographics <ul><li>Malnutrition in Older Adults: </li></ul><ul><ul><li>Independent Living: 1% TO 15% </li></ul></ul><ul><ul><li>Institutionalized: 25% TO 85% </li></ul></ul><ul><ul><li>Hospitalized: 35% TO 65% </li></ul></ul>
    69. 71. Increased Risks <ul><li>Older adults who are malnourished are more likely to experience: </li></ul><ul><ul><li>Longer hospital stays </li></ul></ul><ul><ul><li>Increased hospital costs </li></ul></ul><ul><ul><li>Diminished muscle strength </li></ul></ul><ul><ul><li>Functional impairments </li></ul></ul>
    70. 72. Increased Risks <ul><ul><li>Poor wound healing and development of new pressure ulcers </li></ul></ul><ul><ul><li>Infections </li></ul></ul><ul><ul><li>Post operative complications </li></ul></ul><ul><ul><li>Death </li></ul></ul>
    71. 73. Factors Involved <ul><li>Older adults are at increased risk for malnutrition due to dietary, economic, psychosocial and physiological factors. </li></ul>
    72. 74. Physiological Factors <ul><li>Chronic illnesses </li></ul><ul><li>Medications </li></ul><ul><li>Poor oral health </li></ul><ul><li>Disability </li></ul><ul><li>GI issues </li></ul><ul><li>Changes in taste and reduced sense of thirst </li></ul><ul><li>Other senses: vision, hearing, smell </li></ul>
    73. 75. Screening and Assessment <ul><li>Assessments should include </li></ul><ul><ul><li>Baseline- nutritional patterns, abilities </li></ul></ul><ul><ul><li>Lab results- albumin, prealbumin </li></ul></ul><ul><ul><li>Unintentional weight loss prior to admission </li></ul></ul>
    74. 76. Screening and Assessment <ul><li>Both current weight and weight history are important!! </li></ul><ul><ul><li>Loss of 10 lbs over 6 month period – intentional or unintentional – is a red flag needing further assessment </li></ul></ul>
    75. 77. Screening and Assessment <ul><li>Calorie counts </li></ul><ul><li>Less than 50% eaten document and act! </li></ul>
    76. 78. Screening and Assessment <ul><li>Inconsistencies between reported diet and what you see physically (may indicate poverty or elder neglect/abuse) </li></ul>
    77. 79. Dehydration <ul><li>Quickly becomes a critical problem during periods of illness and is often a primary or secondary reason why the patient is in the hospital </li></ul><ul><li>Hydration status must be performed on all older people; I/Os are very important! </li></ul><ul><li>If a patient is not eating well, chances are they are also not drinking well. </li></ul>
    78. 80. Dehydration <ul><li>Elderly may present differently than younger people, symptoms can be subtle: </li></ul><ul><ul><li>Irritability, confusion, lightheadedness, change in mental status, headache, loss of appetite, lethargy (very tired) or fatigue, low urine output or dark urine, constipation, fecal impaction, infection, muscle weakness </li></ul></ul>
    79. 81. Dehydration <ul><li>Poor skin turgor, dry mouth and lips, subtle change in baseline: families may report “Mom doesn’t seem herself today” </li></ul>
    80. 82. Dehydration <ul><li>Check Orthostatics. A fall in blood pressure of 20MM HG systolic (when going from lying to standing) and/or a rise in pulse by 15 beats per minute often means a person is dehydrated. </li></ul>
    81. 83. Dehydration <ul><li>Lab tests: serum sodium (hypo or hypernatremia), potassium (hyperkalemia), creatinine (not as reliable in elderly), blood urea nitrogen (BUN), urine specific gravity, and urine electrolytes </li></ul>
    82. 84. Dehydration <ul><li>Alleviate dry mouth: </li></ul><ul><ul><li>Avoid caffeine </li></ul></ul><ul><ul><li>Avoid dry, bulky, spicy, salty foods </li></ul></ul><ul><ul><li>Sugarless hard candy or chewing gum to stimulate saliva (not for patients with dementia or dysphagia) </li></ul></ul><ul><ul><li>Applying petroleum jelly to lips or dentures </li></ul></ul><ul><ul><li>Frequent small mouthfuls of water </li></ul></ul><ul><ul><li>Artificial saliva </li></ul></ul>
    83. 85. Be Proactive <ul><li>Improve oral intake: </li></ul><ul><ul><li>Mealtime checks </li></ul></ul><ul><ul><li>Encourage family members </li></ul></ul><ul><ul><li>Small, frequent intake </li></ul></ul><ul><ul><li>Pain meds </li></ul></ul><ul><ul><li>Pleasant environment </li></ul></ul><ul><ul><li>OOB </li></ul></ul>
    84. 86. Be Proactive <ul><li>Cues and Gestures </li></ul><ul><ul><li>Hand over older person’s hand </li></ul></ul><ul><ul><li>Pantomime gestures </li></ul></ul><ul><ul><li>Sit across (Model eating behavior) </li></ul></ul><ul><li>Use adaptive devices and make sure they work: eyeglasses, hearing aids, dentures, sports bottles, straws and cups with lids (tremors) </li></ul><ul><li>Allow time – use finger foods </li></ul>
    85. 87. Be Proactive <ul><li>Difficulty in swallowing referred to SLP. </li></ul><ul><li>Dysphagia occurs in advancing dementia and patient may eventually lose the ability to swallow and eat or drink. </li></ul><ul><li>Supplements </li></ul>
    86. 88. What Do You Think? <ul><li>Which of these situations is an example of nosocomial malnutrition? </li></ul><ul><li>Decreased intake related to a disease process </li></ul><ul><li>Failure to replace meals held for tests </li></ul><ul><li>Anorexia related to an underlying eating disorder </li></ul>
    87. 89. What Do You Think? <ul><li>Malnutrition in a hospital usually refers to </li></ul><ul><li>Carbohydrate- fat intake </li></ul><ul><li>Protein-carbohydrate intake </li></ul><ul><li>Fat-protein intake </li></ul><ul><li>Protein-calorie intake </li></ul>
    88. 90. What Do You Think? <ul><li>A patient who fails to consume adequate calories and protein is at increased risk for which of these complications? </li></ul><ul><li>Thromboembolism </li></ul><ul><li>Heart failure </li></ul><ul><li>Hepatitis </li></ul>
    89. 91. What Do You Think? <ul><li>A patient who develops hypoalbuminemia related to protein deficiency should be monitored for toxicity to which of these meds? </li></ul><ul><li>Warfarin </li></ul><ul><li>Dilantin </li></ul><ul><li>Meperidine </li></ul><ul><li>Digoxin </li></ul>
    90. 92. What Do You Think? <ul><li>Which of these approaches would you use with a patient whose appetite deteriorates throughout the day? </li></ul><ul><li>Limit stimulation at meals </li></ul><ul><li>Encourage a big breakfast </li></ul><ul><li>Reduce physical activity </li></ul><ul><li>Offer double portions </li></ul>
    91. 93. Discharge Planning Collaboration is key
    92. 94. Goals of Session <ul><li>Clarify Myths and Facts </li></ul><ul><li>Purpose of D/C Planning </li></ul><ul><li>High Risk Triggers for D/C Planning </li></ul><ul><li>Basic Needs are Assessments and Resource Management </li></ul><ul><li>Case Scenarios </li></ul>
    93. 95. Myths and Facts <ul><li>1. Only the elderly patient need D/C Planning. T__F__ </li></ul><ul><li>2. The MD must order D/C Planning for all patients needing these services. T__ F__ </li></ul><ul><li>3. Patients are always truthful about their D/C </li></ul><ul><li>Planning needs. T__ F__ </li></ul><ul><li>4. A referral to Social Worker is needed for D/C </li></ul><ul><li>Planning services. T__ F__ </li></ul><ul><li>5. Hospitals must provide D/C Planning services to all patients. T__ F___ </li></ul>
    94. 96. History of Discharge Planning based on Regulatory Influences <ul><li>HCFA ( Health Care Financing Admin.) </li></ul><ul><li>JCAHO (Joint Commission on Accreditation of Healthcare Organizations </li></ul><ul><li>Abuse/ Neglect Legislation </li></ul><ul><li>OBRA Act of 1987 (Omnibus Reconciliation Act) </li></ul><ul><li>Medicare Patient Transfer Act </li></ul><ul><li>Nondiscrimination in Post-Hosp. Referral to Home Health Agencies and other Entities (BBA/1997 ) </li></ul><ul><li>Medicare Discharge Notice Act 2007 </li></ul>
    95. 97. Piedmont Hospital Discharge Planning Policy <ul><li>To promote continuity of care and support patients’ safety for post hospital care and services. </li></ul><ul><li>Involves high risk screening within 24 hrs. of admission to the hospital. </li></ul><ul><li>Must have documentation of assessments with a Plan. </li></ul><ul><li>Recognition of potential discharge delays. </li></ul><ul><li>Discharge Rights Notice and Appeal Rights </li></ul>
    96. 98. High Risk Triggers <ul><li>Patients over 70 years old </li></ul><ul><li>Patients with LOS >7 days </li></ul><ul><li>Chronic or serious illness such as </li></ul><ul><li>CVA,CA, MI, THR, Closed Head/Spinal Cord Injury, HIV+/AIDS, Coma, Multiple Trauma </li></ul><ul><li>Victim of abuse/neglect </li></ul><ul><li>Incompetent, Chronic non compliance </li></ul><ul><li>Homeless, without insurance or without income </li></ul><ul><li>Transferred from another facility: NH, LTAC, Hospice, Hosp. ALF </li></ul>
    97. 99. Standards for Assessments <ul><li>Expected outcome= Plan for safe discharge and avoid inappropriate readmission. </li></ul><ul><li>Accurate assessments are essential to development of appropriate discharge plans. </li></ul><ul><li>Patient components : physical/functional/medical history; emotional/cognitive/behavioral; social/family support; financial </li></ul>
    98. 100. Resource Management Needs Identified <ul><li>In hospital and community resources options </li></ul><ul><li>Problems that may affect discharge planning decisions : delayed consult/ test /procedure/surgery/ lab result; pt/family teaching for home care; multidisciplinary collaboration and communication ( need unit rounds & family meetings) </li></ul><ul><li>Flow chart of options based on needs identified from ongoing assessments. </li></ul><ul><li>Post Hospital Follow-up needed to evaluate effectiveness of D/C Plans </li></ul>
    99. 101. <ul><li>Remember Discharge Planning is a process that we all must share and we need to collaborate and communicate because “ one day we will be on the receiving end of our services”. </li></ul><ul><li>Our goal is safe discharges and safe transitions out of the hospital. </li></ul><ul><li>We want to team-up with you to improve communication flow and links to resources. </li></ul><ul><li>What can we do better?? </li></ul><ul><li>Thank you </li></ul>
    100. 102. Case # 1 What would you do? <ul><li>86 yr. Old female who was visiting her daughter and was admitted to Hosp. for N/V/Abd pain. She had temp 101. Hs. of HTN, AMI, Afib/on chronic coumadin. DM/ diet regulated. </li></ul><ul><li>Admit orders were: Tel,VSq4.I&O;Lovenox SQq12.Reglan IVq6.Card & GI Consult. BL Cult pending. Home meds reconciliation done. </li></ul><ul><li>On 3 rd. day, MD projected for discharge in 1-2 days. All Test neg. VSS. Pt complained of pain intermittently, nutrition consult pending. </li></ul><ul><li>Pt lives alone in MD and a son lives closeby who checks on her and he is still employed. </li></ul><ul><li>She has fallen a couple of times @home and has a housekeeper once a week for chores, shopping, medical appt. </li></ul><ul><li>She was described as pleasant but confused @times but voiced being independent with ADLs. Socially, she attends church weekly and read her bible daily. She has 5 children whom she visited for weeks @ a time. </li></ul><ul><li>Questions: </li></ul><ul><li>Does this case meet High Risk for an assessment? </li></ul><ul><li>This is your case today and you are aware that your Unit LOS is high. </li></ul><ul><li>The test and consults were negative and pt appear to be back @ baseline. MD wrote in progress note that pt may be ready for d/c in 1-2 days. You have “rounds” today, what would you do or consider for this patient? </li></ul><ul><li>What could be some resources for safety of her discharge @ this time? </li></ul>
    101. 103. Case # 2 How would you handle this? <ul><li>Pt age 75 was found wandering and was admitted for CP, suffered cardiac arrest and was vent dependent for several days. He is listed as John Doe. </li></ul><ul><li>He is off vent but unable to recall his name or recall any personal/ family information. Neuro and Rehab evals complete and pt is physically regaining independence but mental/ cognitive deficits remain. </li></ul><ul><li>He has been in hospital 3 weeks and he is your patient today. CM stated that pt is too independent for NH and will need supervision for cognitive deficits but pt has no funds or identification to apply for community resources. </li></ul><ul><li>While in pt’s room, RN noticed that pt. was writing same numbers repeatedly on a picture of a shirt. </li></ul><ul><li>Questions/ concerns : </li></ul><ul><li>How does he meet HR for D/C Planning? </li></ul><ul><li>What are some real barriers to safe discharge planning? </li></ul><ul><li>What are some resources in the hospital and community to consider? </li></ul>
    102. 104. Incontinence <ul><li>Clinical Definition (UI): </li></ul><ul><li>Urine loss of sufficient problem to be perceived as bothersome or it creates a prompt desire to seek care </li></ul><ul><li>An Estimated 16 million people in the U.S. Over 50% Prevalence in the Institutionalized Elderly </li></ul>
    103. 105. Voiding Physiology <ul><li>Cerebral Cortex </li></ul><ul><li>Pontine Micturition Center </li></ul><ul><li>Micturition reflex </li></ul><ul><li>Spinal Cord Pathways Bladder </li></ul><ul><li>Urethral Sphincter </li></ul><ul><li>“ Head to Tail” assessment </li></ul>
    104. 106. Bladder Differences by Gender <ul><li>Female </li></ul><ul><li>Longitudinal Section </li></ul><ul><li>Male Male </li></ul><ul><li>Longitudinal Section Lateral View </li></ul>
    105. 107. Most Prevalent Types – Urinary Incontinence <ul><li>Stress UI: urine loss due to sphincter dysfunction- Prolonged use of a Urinary catheter </li></ul><ul><li>Urge / Over-active Bladder </li></ul><ul><li>Mixed Incontinence: Stress UI + OAB </li></ul><ul><li>An Estimated 90% of UI = Stress, OAB, & Mixed Incontinence </li></ul><ul><li>Total UI: complete loss of sphincter fxn or fistula formation </li></ul>
    106. 108. Most Prevalent Types – Urinary Incontinence <ul><li>Reflex UI: a spinal cord lesion, Reflex Arc is maintained (Bladder filling causes bladder contraction) </li></ul><ul><li>Retention w/ Overflow UI </li></ul><ul><li>Mixed Incontinence: Stress UI + OAB </li></ul><ul><li>An Estimated 90% of UI = Stress, OAB, & Mixed Incontinence </li></ul>
    107. 109. Most Prevalent Types – Urinary Incontinence <ul><li>Total UI: complete loss of sphincter fxn or fistula formation </li></ul><ul><li>Reflex UI: a spinal cord lesion, Reflex Arc is maintained (Bladder filling causes bladder contraction) </li></ul><ul><li>Retention w/ Overflow UI </li></ul>
    108. 110. Other types of Urinary Incontinence <ul><li>Functional UI: normal voiding patterns & normal bladder function; usually related to cognitive status, motivation, and/or mobility issues, environment </li></ul><ul><li>Management </li></ul><ul><ul><li>Prompted / Scheduled voiding </li></ul></ul>
    109. 111. Reversible Factors of Urinary Incontinence - “DIAPPERS” <ul><li>D – Delirium </li></ul><ul><li>I – Infection / Irritants </li></ul><ul><li>A – Atrophic urethritis / vaginitis </li></ul><ul><li>P – Pharmaceuticals </li></ul><ul><li>P – Psychological causes </li></ul><ul><li>E – Endocrine causes (Excess urine) </li></ul><ul><li>R – Restricted Mobility </li></ul><ul><li>S – Stool impaction </li></ul>
    110. 112. Effects of Aging R/T Continence <ul><li>Increased nocturia (1-2x/night >60) </li></ul><ul><li>Bladder fills full at lower volumes </li></ul><ul><li>Reduced strength of bladder contractions </li></ul><ul><li>Increased irritability of bladder </li></ul><ul><li>Delayed recognition of bladder filling </li></ul><ul><li>Adequate fluid intake? </li></ul>
    111. 113. Indwelling Foley Catheters <ul><li>30-40% of HAI </li></ul><ul><li>Risk for UTI 1-2% for a single insertion </li></ul><ul><li>Increases to 5-8% per day with indwelling catheter </li></ul><ul><li>CAUTIs- one of CMS Never Events </li></ul>
    112. 114. Foley Catheters in ED <ul><li>CAUTIs- one of CMS Never Events </li></ul><ul><li>Most effective method to prevent CAUTIs is to avoid indwelling cathters </li></ul><ul><li>If MUST have- then aseptic technique, closed system, secured to leg </li></ul>
    113. 115. Indications for a Urinary Catheter <ul><li>Critically Ill : Alteration in BP or volume status requiring continuous, accurate urine volume measurement </li></ul><ul><li>Infection Prevention : to prevent urine from soiling a Stage III or IV pressure ulcer or nearby operative site </li></ul><ul><li>Comfort care : for terminally ill patients </li></ul><ul><li>Surgery : patients going directly to the operating room </li></ul><ul><li>Procedures or Tests requiring an indwelling urinary catheter, removed at the conclusion of the procedure/test </li></ul><ul><li>GU Indications </li></ul><ul><ul><li>Continuous bladder irrigation </li></ul></ul><ul><ul><li>Instillation of medication into the bladder </li></ul></ul><ul><ul><li>Obstruction to the urinary tract distal to bladder </li></ul></ul><ul><ul><li>Drainage in patient with neurogenic bladder dysfunction, hydronephrosis, and urinary retention not manageable by other means (e.g., with clean intermittent catheterization) </li></ul></ul><ul><ul><li>Aid in urologic surgery or other surgery in contiguous structures </li></ul></ul><ul><ul><li>Ordered by a urologist for a special purpose or difficult insertion </li></ul></ul>
    114. 116. When NOT to use a Catheter? <ul><li>An indwelling urinary catheter is not appropriate for nursing convenience or for urinary incontinence in the absence of skin breakdown. </li></ul>Use CAUTION = Prevent C.A.U.T.I. C – Closed system A – Aseptic mgmt of indwelling catheter U – Use standard precautions T – Tubing secured to leg & clipped to sheet I – Indications (do I still need it?) O – Obstruction free N – No dependent loops
    115. 117. ED <ul><li>Gateway for most of our older patients </li></ul><ul><li>Ability to initiate change in practice that will carry through the admission </li></ul><ul><li>Eliminate a risk that prolongs LOS and had financial impact </li></ul>
    116. 118. Definition of a Restraint: <ul><li>A physical restraint is any “manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move his/her arms, legs, body, or head freely.” (CMS- federal register, p 71389) </li></ul><ul><li>A chemical restraint is a drug or medication used as a restriction to control the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. </li></ul><ul><li>A forensic restraint is the use of handcuffs or other restrictive devices applied by law enforcement for custody, detention, and public safety reasons. They are not involved in the provision of health care by law enforcement. </li></ul>
    117. 119. Patient Rights <ul><li>Every patient has the right to expect…. </li></ul><ul><li>Care that is respectful, high-quality, considerate with dignity </li></ul><ul><li>Participation in decisions about treatment, benefits, risks, alternatives </li></ul><ul><li>Consideration of personal beliefs and values </li></ul><ul><li>provision for privacy </li></ul><ul><li>Any restraint to be humanely and professionally administered </li></ul>
    118. 120. Negative Consequences of Restraint Use: <ul><li>Physical </li></ul><ul><li>Pressure Ulcers </li></ul><ul><li>Decreased circulation </li></ul><ul><li>Muscle atrophy </li></ul><ul><li>Decreased metabolism </li></ul><ul><li>Increased incidence of aspiration pneumonia </li></ul><ul><li>Constipation </li></ul><ul><li>Dehydration </li></ul><ul><li>Incontinence </li></ul><ul><li>Behavioral </li></ul><ul><li>Agitation, Confusion, Anger </li></ul><ul><li>Emotional regression and mental withdrawal </li></ul><ul><li>Loss of self esteem </li></ul><ul><li>Embarrassment or humiliation </li></ul><ul><li>Loss of independence </li></ul><ul><li>Reduced social contact </li></ul>
    119. 121. Restraint Alternatives <ul><li>Before an actual restraint can be used, the regulations require that other ways to handle the situation be tried first and documented such as: </li></ul><ul><ul><ul><li>Companionship/supervision </li></ul></ul></ul><ul><ul><ul><li>Communication </li></ul></ul></ul><ul><ul><ul><li>Teaching </li></ul></ul></ul><ul><ul><ul><li>Change in Treatments </li></ul></ul></ul><ul><ul><ul><li>Diversion </li></ul></ul></ul><ul><ul><ul><li>Environmental changes </li></ul></ul></ul>
    120. 122. Alternatives for Patient Interference with Medical Devices <ul><li>Addressing the discomfort associated with the treatment in a quiet and calm way </li></ul><ul><li>Explaining the situation/procedure or giving information about the problem </li></ul><ul><li>Evaluate need for treatment device </li></ul><ul><li>As soon as possible, initiate oral feeding, remove catheters and drains, change continuous IV medications to intermittent or other route </li></ul><ul><li>Camouflage or pad IV and other tubing or dressings with gauze or stocking </li></ul><ul><li>Provide frequent care of feeding tubes, catheters and other tubes </li></ul>
    121. 123. Alternatives for Fall Prevention <ul><li>Scheduled toileting individualized to patient’s needs and pattern (may also eliminate the need for an indwelling urinary catheter) </li></ul><ul><li>Proper lighting </li></ul><ul><li>Complete fall risk assessment, including gait, use of assistive devices, toileting problems </li></ul><ul><li>Early involvement of PT and OT to assist with assessment and formulation of mobilization plan </li></ul><ul><li>Establish “safe periods” in which restraints are removed and the patient is monitored closely during the night </li></ul>
    122. 124. Facilitate the Patient’s Environment <ul><li>Use visual clues such as schedules, calendars and clocks </li></ul><ul><li>Labels on floor and doors to help orient patients and prevent wandering in restricted areas </li></ul><ul><li>Use a wedge cushion to prevent a patient from sliding out of a wheelchair </li></ul><ul><li>Non-skid floors or non-skid mats around beds and other areas </li></ul><ul><li>Use non-glare lighting and nightlights to provide clear visual recognition </li></ul>
    123. 125. Diversion <ul><li>Take the patient’s mind off the situation by diverting his/her attention to something else such as: </li></ul><ul><ul><ul><li>Watching television </li></ul></ul></ul><ul><ul><ul><li>Listening to music </li></ul></ul></ul><ul><ul><ul><li>Talking on the phone </li></ul></ul></ul><ul><ul><ul><li>Reading books or magazines </li></ul></ul></ul>
    124. 126. Least Restrictive Restraint <ul><li>When alternative methods fail to keep the patient and others safe, use the LEAST RESTRICTIVE RESTRAINT possible. </li></ul>
    125. 127. Restraint Use <ul><li>Each time a restraint is used it must be reported to your supervisor or clinical leadership as soon as possible. </li></ul><ul><li>Each time a restraint is used it must be documented on the patient’s chart. </li></ul><ul><li>Each restraint use must have a physician’s order </li></ul>
    126. 128. Important to Remember <ul><li>Always remember that restraints/seclusion are prohibited when used as a means of “coercion, discipline, convenience, or retaliation by staff’ in any setting </li></ul><ul><li>CMS, 12/2006 </li></ul>
    127. 129. Definition of a Restraint: <ul><li>A physical restraint is any “manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move his/her arms, legs, body, or head freely.” (CMS- federal register, p 71389) </li></ul><ul><li>A chemical restraint is a drug or medication used as a restriction to control the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. </li></ul><ul><li>A forensic restraint is the use of handcuffs or other restrictive devices applied by law enforcement for custody, detention, and public safety reasons. They are not involved in the provision of health care by law enforcement. </li></ul>
    128. 130. Patient Rights <ul><li>Every patient has the right to expect…. </li></ul><ul><li>Care that is respectful, high-quality, considerate with dignity </li></ul><ul><li>Participation in decisions about treatment, benefits, risks, alternatives </li></ul><ul><li>Consideration of personal beliefs and values </li></ul><ul><li>provision for privacy </li></ul><ul><li>Any restraint to be humanely and professionally administered </li></ul>
    129. 131. Negative Consequences of Restraint Use: <ul><li>Physical </li></ul><ul><li>Pressure Ulcers </li></ul><ul><li>Decreased circulation </li></ul><ul><li>Muscle atrophy </li></ul><ul><li>Decreased metabolism </li></ul><ul><li>Increased incidence of aspiration pneumonia </li></ul><ul><li>Constipation </li></ul><ul><li>Dehydration </li></ul><ul><li>Incontinence </li></ul><ul><li>Behavioral </li></ul><ul><li>Agitation, Confusion, Anger </li></ul><ul><li>Emotional regression and mental withdrawal </li></ul><ul><li>Loss of self esteem </li></ul><ul><li>Embarrassment or humiliation </li></ul><ul><li>Loss of independence </li></ul><ul><li>Reduced social contact </li></ul>
    130. 132. Restraint Alternatives <ul><li>Before an actual restraint can be used, the regulations require that other ways to handle the situation be tried first and documented such as: </li></ul><ul><ul><ul><li>Companionship/supervision </li></ul></ul></ul><ul><ul><ul><li>Communication </li></ul></ul></ul><ul><ul><ul><li>Teaching </li></ul></ul></ul><ul><ul><ul><li>Change in Treatments </li></ul></ul></ul><ul><ul><ul><li>Diversion </li></ul></ul></ul><ul><ul><ul><li>Environmental changes </li></ul></ul></ul>
    131. 133. Alternatives for Patient Interference with Medical Devices <ul><li>Addressing the discomfort associated with the treatment in a quiet and calm way </li></ul><ul><li>Explaining the situation/procedure or giving information about the problem </li></ul><ul><li>Evaluate need for treatment device </li></ul><ul><li>As soon as possible, initiate oral feeding, remove catheters and drains, change continuous IV medications to intermittent or other route </li></ul><ul><li>Camouflage or pad IV and other tubing or dressings with gauze or stocking </li></ul><ul><li>Provide frequent care of feeding tubes, catheters and other tubes </li></ul>
    132. 134. Alternatives for Fall Prevention <ul><li>Scheduled toileting individualized to patient’s needs and pattern (may also eliminate the need for an indwelling urinary catheter) </li></ul><ul><li>Proper lighting </li></ul><ul><li>Complete fall risk assessment, including gait, use of assistive devices, toileting problems </li></ul><ul><li>Early involvement of PT and OT to assist with assessment and formulation of mobilization plan </li></ul><ul><li>Establish “safe periods” in which restraints are removed and the patient is monitored closely during the night </li></ul>
    133. 135. Facilitate the Patient’s Environment <ul><li>Use visual clues such as schedules, calendars and clocks </li></ul><ul><li>Labels on floor and doors to help orient patients and prevent wandering in restricted areas </li></ul><ul><li>Use a wedge cushion to prevent a patient from sliding out of a wheelchair </li></ul><ul><li>Non-skid floors or non-skid mats around beds and other areas </li></ul><ul><li>Use non-glare lighting and nightlights to provide clear visual recognition </li></ul>
    134. 136. Diversion <ul><li>Take the patient’s mind off the situation by diverting his/her attention to something else such as: </li></ul><ul><ul><ul><li>Watching television </li></ul></ul></ul><ul><ul><ul><li>Listening to music </li></ul></ul></ul><ul><ul><ul><li>Talking on the phone </li></ul></ul></ul><ul><ul><ul><li>Reading books or magazines </li></ul></ul></ul>
    135. 137. Least Restrictive Restraint <ul><li>When alternative methods fail to keep the patient and others safe, use the LEAST RESTRICTIVE RESTRAINT possible. </li></ul>
    136. 138. Restraint Use <ul><li>Each time a restraint is used it must be reported to your supervisor or clinical leadership as soon as possible. </li></ul><ul><li>Each time a restraint is used it must be documented on the patient’s chart. </li></ul><ul><li>Each restraint use must have a physician’s order </li></ul>
    137. 139. Important to Remember <ul><li>Always remember that restraints/seclusion are prohibited when used as a means of “coercion, discipline, convenience, or retaliation by staff’ in any setting </li></ul><ul><li>CMS, 12/2006 </li></ul>

    ×