3. General Care Concerns


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3. General Care Concerns

  1. 1. General Care Concerns 20091201 Heejeong, Kim.
  2. 2. General Care Concerns• Nutrition and Hydration• Rest and Sleep• Comfort and pain management• Safety• Safe Medication Use
  3. 3. Nutrition and Hydration
  4. 4. Causes or contributing factors Nursing DiagnosisTeeth have Various degree of erosion; Imbalance NutritionAbrasions of crown and root structure Less than body requirements relatedHigh prevalence of tooth loss to limited ability to chew foodReduction in saliva to approximately Imbalanced Nutritionone-third the volume of earlier years Less than body requirements related to less efficient mixing foodsInefficient digestion of starch due to Imbalanced Nutritiondecreased salivary ptyalin Less than body requirements related to reduced breakdown of starchesAtrophy of epithelial covering in oral Impaired oral mucous membranemucosaIncreased taste threshold Disturbed Sensory Perception:Approximately one-third of number of gustatory.functioning taste buds per papilla of Imbalanced Nutrition:earlier years More than body requirements related to excessive intake of salts and sweets to compensate for taste alterations
  5. 5. Causes or contributing factors Nursing DiagnosisDecreased thirst sensation; reduced Imbalanced Nutritionhunger contractions Less than body requirements related to reduced ability to sense hunger sensations Deficit fluid volume related to decreased thirst.Decreased esophageal peristalsis Risk for injury from aspirationReduced stomach motilityLess hydrochloric acid, pepsin, and Imbalanced Nutritionpancreatic acid produced stomach Less than Body requirements relatedmotility to in effective break down of foodLower fat tolerance Pain related to indigestionDecreased colonic peristalsis Imbalanced NutritionReduced sensation for signal to Less than Body requirements relateddefecate. to reduced appetite
  6. 6. Nutrition and Hydration• Harris-Benedict equation (Resting Energy Expenditure) Males66+[13.7* weight(kg)] + [5* height(cm) ] -[6.8*age]= Kcal/day Female65.5+[9.7* weight(kg)] + [1.8* height(cm) ] -[4.7*age]= Kcal/day
  7. 7. Hydration• Hydration needs of older adultsTo a reduced fluid intake or increased loss that would be only a minor problem in a younger person could be life –threatening to an older person.
  8. 8. Nurses evaluate older adults for factors that can cause them to consume less fluid, such asHydration ① Age related reductions in thirst sensation ② Fear of incontinence(physical condition and lack of toileting opportunities ③ Lack of accessible fluids ④ Inability to obtain or drink fluids independently ⑤ Lack of motivation ⑥ Altered mood or cognition ⑦ Nausea, Vomiting, gastrointestinal distress,
  9. 9. Dry skin Dehydration Sunken  Concentrated cheeks urine  Blood urea value <60 mg/dl  Confusion Brown tongue
  10. 10. Promotion of oral healthPoor dental Changes in gingival tissuecare ① Periodontal disease a. Bleeding gums(when teeth are brushed) b. Red swollen, painful Environmental gums influences c. Chronic bad breath ② Tooth loss Inappropriate nutrition
  11. 11. Key ConceptDental problems can affect virtually every system ofthe body:Therefore, they must be identified and correctedpromptly.
  12. 12. NutritionA variety of Physical, psychological, andsocioeconomic factors influence nutritional status.
  13. 13. Threats to Good Nutrition1. Indigestion and Food intolerance① Decreased stomach motility Nurse can suggest② Less gastric secretion eating several③ Slower gastric emptying time small meals2. Anorexia- anorexia can be related to a variety of conditions① Medication side effects② Inactivity③ Physical illness or age related changes(such as decreased taste and smell sensations)④ Reduced production hormone leptin.⑤ Gastric change⑥ Losses and stresses(e.g.; death of love ones, loneliness, financial worries) could cause anxiety and depression that could effect appetete.
  14. 14. Threats to Good Nutrition3. DysphagiaDifficulty moving food from the mouth to the esophagus(transferDysphagia), down the esophagus(transport dysphagia) from theesophagus into the stomach(delivery dysphagia)① Neurologic condition such as a strock② Most cases result from gastro esophageal reflux disease(GERD)*Having the person sit upright whenever food or fluid is being consumed*Allowing sufficient time for eating*Ensuring there is no residual food in the mouth before feeding additional food.4. Constipation① Slower peristalsis② Inactivity③ Side effects of drugs(codein)④ Tendency toward less fiber and fluid in the diet.5. Malnutrition
  15. 15. Rest and Sleep
  16. 16. Rest and Sleep• Age-related changes in Sleep1. Circadian sleep-Wake cycles2. Sleep Stages3. Sleep Efficiency and quality• Sleep disturbances1. Insomnia2. Nocturnal Myoclonus and Restless leg Syndrome3. Sleep Apnea4. Medical Conditions that Affect Sleep5. Drugs that affect Sleep• Promoting rest and Sleep in Older adults1.Pharmacologic measures to promote Sleep2.Nonphamacologic measures to promote sleep3.Pain control
  17. 17. Age-related Change in Sleep• Insomnia, daytime sleeping, and napping are all highly prevalent among the older adults.• These experiences results from age-related changes in circadian sleep-wake cycles
  18. 18. Age-related Change in Sleep• Circadian Sleep-Wake Cycles① To fall asleep earlier in the evening② To awaken earlier in the morning③ The quantity of sleep does not change but the hours in which it occurs may
  19. 19. Age-related Change in Sleep• Sleep StageStage Characteristics Difference in Older AdulthoodNREM I Begins nodding off More time spent in this stage, most Can be easily awakened likely due to frequent awakening II Deeper stage of relaxation reached No significant change III Early phase of deep sleep Decreased Reduced temperature and heart rate, Muscle relaxed. More difficult to be awakened. IV Deep sleep and relaxation May disappear completely in extreme All body functions reduced old age Considerable stimulation needed to be awaken Insufficient stage IV sleep can cause emotional dysfunction.REM Rapid Eye Movement(REM) occurs Decreased due to reduced amount of increased vital signs sleep time in general Will enter REM sleep approximately once ( Certain drugs can also decreased every 90 minutes of stage IV sleep REM sleep, including alcohol, Insufficient REM sleep can cause barbiturates, and phenothiazine emotional dysfunction, including psychosis derivatives.
  20. 20. Age-related Change in Sleep Nurses need to be aware that older adults can be easily awakened by noise and lighting associated with caregiving and other staff activities during the night
  21. 21. Sleep disturbance• Sleep disturbance① Insomniaa. Difficulty falling asleepb. Do not sleep soundlyc. Travel to the bathroom several times during the night.d. Can be short term problem associated with change environmemtal, illness, added stress, or anxiety.e. Chronic insomnia(lasting 3 or more weeks) can be related to physical or mental illnesses, substance abuse, or medications
  22. 22. Sleep disturbance• Sleep disturbance② Nocturnal Myoclonus and Restless Leg SyndromeJerking leg movements during sleep can cause awakenings duringthe night.* Associated with Tricyclic antidepressants and chronic renal failure③ Sleep Apnea④ Medical conditions that affect sleep.a. Hypnotics interfere with REM and deep sleep stages and can cause daytime drowsiness
  23. 23. Sleep disturbance • Sleep disturbance ⑤ Drugs that affect Sleepcharacteristics Drug Affecting resultsAntidepressents MAOI, SSRI Inhibited with REMAntipsychotics Haloperidol Change with REM RisperidonHypotonics, sedatives Barbiturate Interfere with REM and deep Benzodiazepine. sleep stage and can cause daytime drowsinessDiuretics Acetazolamide bathroom several times during the night.Anticholinergics ScopolamineΒ-adrenoreceptor Propranololantagonists Metopronolα-adrenoreceptor agonists Clonidine MethydopaSmooth muscle relaxants Hydralazine Sleeping disturbance.
  24. 24. •diphenhydramine HCL(Benadryl capsules)•Nicotine(NicoDerm Nicotine NonprescriptionTransdermal System) sleep aids•Theophilline•Alprazolan(xanax) Contain dephenydramamine (Benadryle) Should be avoided High cholinergic side effects in older adults
  25. 25. Caffeine as Contributor to poor Sleep Source: National Sleep Foundation. Caffeine calculator. http://www.sleepfoundation.orgCappuccino 120mg/8-ounce servingCoffee 85-110Tea 46-60Shasta Cola 45Pepsi ONE 37Mountain Dew 34Diet Coke 31Sunkist Orange Soda 28Iced tea 25Diet Pepsi 24Coca cola 23Decaf espresso 10
  26. 26. Promoting Rest and Sleep in old adults• Pharmacologic measures to promotes Sleep.① Barbiturates are general depressants, especially to the central nervous system significantly depress some vital body functionsa. Lowering basal metabolic rateb. Decreasing blood pressurec. Decreasing mental activityd. Decreasing peristasis• Nonpharmacological measures to promote Sleep① Activity and Rest Schedules.② Environment③ Food and supplements④ Stress management⑤ Pain control
  27. 27. Comfort and Pain management
  28. 28. Comfort• Define comfort1. Derived from the Latin word “ confortare”which means to strengthen greatly2. Webster’s Dictionary :“ to relieve from distress, lessen misery, have freedom from pain and worry, calm, and inspire with hope3. Holistic perspective: “Can be viewed as a sense of physical, emotional, social, and spiritual peace and well being.**Unfortunately, with advancing age, the incidence of factors that can threaten comfort increase
  29. 29. Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage (American Pain Society, 2003) Prevalence of pain in older Adults (PR Newswire,2000)① More than 4 of 10 people report experiencing pain on a daily basis.② With majority(89%) saying that they experience pain each month③ Low back pain is among the most common complaints, along with migraine or severe headache, and joint pain, aching, or stiffness④ The knee is the joint that causes the most pain according to the report(Increasingly Knee replacement surgeries have risen dramatically for people over age 65.
  30. 30. The complex phenomenon of pain is astressor to physical, emotional, andspiritual well-being
  31. 31. Types of PainPathophysiological mechanismNociceptive (Tissue) PainNociceptive pain results from mechanical, thermal,orChemical noxious stimuli to the A delta and C afferentnociceptorsNociceptive pain can be subdivided into①somatic : bone and soft tissue masses, localized,describe as Throbbing or Aching②visceral (gut) pain.: Generalized or referred painNeuropathic (Nerve) PainExamples of neuropathic pain include① diabetic neuropathy,② trigeminal neuralgia,③ postherpetic neuralgias.(peripheral pains)④ thalamic pain syndrome (a central pain).The pain is Sharp, stabbing, tingling, or burning, which a sudden onset
  32. 32. 척수: Spinal cord• Inside the spinal cord
  33. 33. Types of PainOnset and DurationAcute PainAbrupt onset, can be severe, but lasts only a short time.Chronic PainHas persisted for three months or longer
  34. 34. Assessing pain• Good rapport with patient and use therapeutic communication skills• History and risk factors• Subjective presentation• Objective presentation• Vital sign and hemodynamics www.themegalllery.com
  35. 35. History and risk factors- P Q R S TPalliating factors:① What makes the pain better?② What do you do to get relief?③ What helps you?Provocative factors:① What makes the pain worse?② What brings it on?③ What aggravates it?Quality of pain:① What does the pain feel like?② What words would you use to describe it?.Radiation: 또는 Region① Where is the pain?② Does the pain go anywhere else?③ Does it spread?Severity:① How bad is the pain?② Mild, moderate, severeTime:• On set 등(recent, promote) www.themegalllery.com
  36. 36. www.themegalllery.com
  37. 37. Subjective presentation• Pain is subjective• Should be asked to describe the nature of pain• (location, intensity, quality, the timing of the pain, aggravating/alleviating factors)• NRS(Numeric scale)• VAS(Visual analog scale)• ARS(Adjective rating scale) www.themegalllery.com
  38. 38. -Pain Assessment Tool- Neumeric Rating Scalewww.themegalllery.com
  39. 39. Visual Analog scalewww.themegalllery.com
  40. 40. Adjective Rating scale Patient select an adjective that best describes the pain intensitywww.themegalllery.com
  41. 41. Objective presentation*Used self report 또는 의식이 없을 때 가족이나 친지• Physiologic ANS stimulation과 관계있는지 사정한다. Autonomic Indicators pain Diaphoresis, pallor Vasoconstriction Increased systolic and diastolic BP Pulse rate> 100회/ min Papillary dilation Change respiratory rate( 20회 이상) Musle tension or spasm Endocrine imbalance(evidence sodium and water retension and mild hyperglycemia)• BehavioralSocial , cultural, ethic, and environmental factorsNonverval indicators참조. www.themegalllery.com
  42. 42. **Skeletal muscle tension① Facial grimace, tension ② 아픈 부위의 Guarding ③ Restlessness④ Decreased motor activity **Psychic reactions ① Short attention span ② Irritability ③ Anxiety ④ Sleep disturbance ⑤ Anger ⑥ Crying ⑦ Fearfulness ⑧ Withdrawal
  43. 43. Signs That Could Indicate pain Persons with Cognitive Impairments Splinting orGrimacing Perspiration guarding body part Increased Crying, pacing, Agitatingmoaning wanderingIncreased Aggressive Changing inVital sign behaviors sleep pattern
  44. 44. Pain Management
  45. 45. Pain managementsComplementary TherapiesDietary TherapiesMedicationComforting.
  46. 46. Complementary Therapies Noninvasive non-drug pain managementExerciseManual techniquesBehavioral modificationCutaneous stimulationElectrotherapy www.themegalllery.com
  47. 47. Noninvasive pharmacologic pain management (Medication) Analgesics Nonsteroidal anti-inflammatory agents (NSAIDs) Muscle relaxants Narcotic medications Antidepressants and anticonvulsants www.themegalllery.com
  48. 48. ComfortingHealing is not synonymous being cured.Rather, it implies living in harmony and peacewith a health condition.
  49. 49. Safety•Aging risks to safety•Importance of the Environmental Health andwellness•Impact of Aging on Environmental Safetyand Function•The problem of Falls•Interventions to reduce Intrinsic Risks toSafety
  50. 50. Aging risks to safety• Age-related changes can reduce the capacity of older adults to protect themselves from injury and increase their vulnerability to safety hazards.
  51. 51. Aging and Risks to safetyDecreased intracellular fluidLoss of subcutaneous tissue: less natural insulation; Lower BMRDecreased efficiency of heartReduced strength and elasticity of respiratory muscleReduces oxygen use under stressPoor condition of teethWeak gag reflexAltered taste sensation Reduced incomeReduction in filtration of wastes by kidneysHigher prevalence of urinary retention more alkaline vaginal secretionsDecreased muscle strength, Demineralized of boneDelayed response and reaction time Poor vision and hearingReduced lacrimal secretions Distorted depth secretionIncreased threshold for pain and touchLess elacicity, more dryness, fragility of skinPoor short-term memory High prevalance of polypharmacy
  52. 52. Impact of Aging on Environmental Safety andFunction
  53. 53. Risk Factors for Falls• Age related Factors① History of falls② Female aged 75 and older③ Impaired vision A program to④ Gait disturbance prevent falls is⑤ Postural hypotension essential to settings⑥ TIA that provide services to older adults⑦ Cerebrovascular accident⑧ Diabetes mellitus⑨ Peripheral vascular disease⑩ Foot problem⑪ Multiple diagnosis
  54. 54. Risk Factors for Falls• Health conditions or functional impairments① Physical disability② Incontinence, nocturia③ Delirium, Dementia④ Mood disturbance⑤ Dizziness⑥ Weakness⑦ Fatigue⑧ Ataxia⑨ Paralysis⑩ Edema⑪ Use Cane, walker, wheelchair, crutch, or brace⑫ Presence of IV, indwelling catheter⑬ Neurologic disease(Parkinsonism)
  55. 55. Risk Factors for Falls• Medication① Antidepressants② Antihypertensives③ Antipsychotics④ Diuretics⑤ Sedatives⑥ Tranquilizers⑦ Multiple medication• Environmental Factors① Newly admitted to hospital/nursing home② Unfamiliar environmental⑪ Highly polished floors⑫ Inadequate environmental lighting⑬ Absence of railings, grab bars.
  56. 56. Interventions to reduce Intrinsic Risks to Safety = prevention• Reducing Hydration and Nutrition Risks• Addressing Risks Associated with Sensory Deficits• Addressing Risks associated with mobility Limitations• Monitoring body temperature• Preventing Infection• Suggesting Sensible Clothing• Using medication Cautionusly• Avoiding Crime.
  57. 57. Safe medication UseEffects of Aging Medication UsePromoting the Safe Use of Drugs
  58. 58. Effect of Aging on Medication Use• Drug use by older adults has been steadily increasingly every year ; a majority of older people use at least one drug regularly, with more typical situation involving the use of several drugs(Skufca, 2007).• The most used common drugs by the older population include• 우리나라 65세 이상 노인의 94%가 약물을 사용하고 있고 처방 약과 비처방약을 함께 사용하고 있는 경우는 66% 처방약물로는 관절염 및 신경계통약, 고혈압약, 당뇨약, 위장관 약 순. 비처방약물로는 영양제, 소염진통제, 소화제 순 재가노인의 경우 94.2%가 평균 4.2개의 약물 복용.① Cardiovascular agents ②Antihypertensive③ Analgesics ④ Antiarthritic agents ⑤Sedatives⑥ Tranqulizers ⑦Laxatives ⑧antaacids
  59. 59. Effect of Aging on Medication Use• Altered Physical mechanism• Altered Pharmacokinetics1. Absorption① No change bioavailability, 그러나 에너지를 요하는 능동 수송은 감소하여 그 결과 일부 약물은 생체 이용률이 감 소한다(예, 칼슘함유 제산제)2. Distribution① 수용성 약의 분포 용적은 감소하며 농도는 증가한다.② 지용성 약물의 분포 용적은 증가하며 반감기는 증가한다.
  60. 60. Effect of Aging on Medication Use• Altered Pharmacokinetics3. Altered PharmacodynamicsPharmacodynamics refers to the biologic andtherapeutic effects of drugs at the site of action or onthe target organ① Increased myocardial sensitivity to anesthesia② Increased central nervous system receptor sensitivity to narcotics, alcohol4. Increased Risk of Adverse ReactionsThis risk of adverse drug reactions is high in older adults because of agerelated differences in pharmacokinetics and pharmacodynamics① Signs and Symptoms ②A prolonged time-adverse effect③ After the drug has been discontinued- Adverse reaction④ Long period time of without problems- Adverse reaction can develop suddenly.
  61. 61. Effect of Aging on Medication Use• Altered Pharmacokinetics4. Increased Risk of Adverse ReactionsOlder adults easily may become victims of drug-induced cognitive dysfunction① Varying degrees of mental dysfunctiona. Codeinb. Digitalisc. Methyldopad. Phenobarbitale. L-dopaf. Diazepam(valium)g. diuretics
  62. 62. Adverse Reaction inappropriate drugs in older populations1. Postural hypotensionTricyclic-antidepressants,① 항고혈압성 약물② α-receptor blocking(수용체 길항체)효과를 나타내는약물(삼환계항우울제,phenothiazines),중추신경으로부터 교감신경방출을 감소시키는 약물(barbiturate,bezodiazephnes, antihistamine, morphine)2. Unstable position선조체(corpus striatum)에서 Dopamine(D2)수용체가 감소하기 때문이다.① 수면제, 진정제 같은 약물은 postural sway를 증가시킴으로 노인이 잘 넘어진다.3. Hypothermia,① benzodiazepines, opioids, alcohol 등이 노인들에게 갑자기 체온저하를 유발할 수 있다.4. cognitive dysfunction① Anticholinergics, sedatives, H2-antagonist, β-adrenoreceptor blocker등이 혼동 유 발5. Decreased GI Mortility① Anticholinergics, tricyclic-antidepressants,antihistamines같은 약물이 변비 또는 장 폐색을 유발하기 쉽다.
  63. 63. Promoting the safe use of drugs
  64. 64. Reviewing necessity and Effectiveness of Prescribed Drugs• Nurse should review all prescription and nonprescription medications used by patients.1. Why is the drug ordered?2. Is the smallest possible dosage ordered?3. Is the patients allergic to the drug?4. Can this drug interact with other drugs, herbs or nutritional supplements that are being used?5. Are there any special instructions accompanying the drug’s administration?6. Is the most effective route of administration being used.
  65. 65. 노인에게서 약물-질병 간의 상호작용약물 질병α-차단제 요실금항콜린성 항히스타민제 양성 전립선 비대증, 변비아스피린>325mg/dl 소화성궤양β-작용제 불면증β-차단제 천식, 만성 폐색성 페질환, 당뇨,심부전,NSAID 만성신부전,심부전,고혈압,소화성궤양Thiazide이뇨제 통풍삼환계 항우울제 부정맥, 방실분리,기립성저혈압.
  66. 66. 노인의 약물에 관한 간호중재1. 노인의 특수성2. 노인의 약물치료원칙① 가급적 약물을 사용하지 않는다② 새로운 약물 추가시 기존 약물과 상호작용 가증성이 있는 것은 피한다③ 적은 용량으로 시작④ 불필요한약 물 장기간 복용금지⑤ 약물이 주로 신장 배설약이면 연령과 신기능 감안.⑥ 약물투여 방법 단순화- 약물복용이행도를 증가
  67. 67. 노인의 약물사용 관리는 노인의 인지기능,기억력,시력,투약보조자 유무 등 노인의 상황에근거한 실제적이고 효과적인투약교육 프로그램의 개발과약물오용 행위를 예방할 수 있는 투약계획표, 개별 약상자등 투약보조방법의 활용 등이관건이다.