![Reality in ED? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
Recommended
More Related Content
Viewers also liked
Viewers also liked (20)
Similar to Emergency Department and Outpatient Senior Healthcare Consultant Course
Similar to Emergency Department and Outpatient Senior Healthcare Consultant Course (20)
Recently uploaded
Recently uploaded (20)
Emergency Department and Outpatient Senior Healthcare Consultant Course
- 1. Atypical Disease Presentation in Older Adults Dee Tucker, MS, RN, GCNS-BC Clinical Nurse Specialist Gerontoloy Piedmont Healthcare NICHE Coordinator
- 8. Signs and Symptoms Learn baseline prior to illness Remember aging changes Recognize presenting symptoms
- 11. Presenting Symptoms Signs and symptoms in older patients are generalized and can represent any number of medical situations.
- 23. Older Patients in the ED: Best Practices Dee Tucker RN, MN, GCNS-BC Clinical Nurse Specialist Gerontology Piedmont Hospital
- 34. MMSE Orientation : year, season, date, day, month 5 points State, county, town, hospital, floor 5 points Registration : Name 3 objects; ask pt to repeat; 1 point for each correct 3 points Attention and calculation : spell “world” forwards, then backwards OR Subtract 7 from 100 5 times 5 points Recall: ask for 3 objects given earlier 3 points Language : Show pencil and watch- ask to name 2 points Ask to repeat “ No ifs, ands or buts” 1 point Follow 3 stage command “Take this paper in your right hand, Fold it in half and place it on the floor” 3 points Read and Obey “Close Your Eyes” 1 point Write a sentence 1 point Copy the design intersecting pentagons 1 point
- 45. Pressure Ulcer Prevention in the ED
- 64. Urinary Incontinence and the ED
- 75. Pain in Older Adults Dee Tucker RN, MN, GCNS-BC Clinical Nurse Specialist Gerontology Piedmont Hospital
- 87. Health Literacy in Older Adults Patient/Family Issues
- 94. Examples of Some Patient Issues and Misunderstandings
- 105. Questions?
- 106. Geriatric Syndromes Dee Tucker, MS, RN, GCNS-BC Clinical Nurse Specialist Gerontology Piedmont Healthcare NICHE Coordinator
- 143. Transitioning Older Patients to community, facility or into hospital Tim Young, LCSW Sixty Plus Older Adult Services
- 154. Discharge Instructions and Older Patients Assess knowledge, barriers Limit Objectives Address barriers Provide scenarios “ Take home” materials
- 155. Medications and Older Adults Critical Thinking NaaDede Badger, Pharm.D, BCPS
- 176. Inappropriate medications in the elderly Sedatives & Hypnotic agents Chlordiazepoxide (Librium ® ) Antidepressants Amitriptyline (Elavil ® ) Antihypertensive agents Methyldopa Propranolol (Inderal ® ) Reserpine Analgesic agents Indomethacin (Indocin ® ) Propoxyphene (Darvon ® ) **also in Darvocet ® Pentazocine (Talwin ® ) Meperidine (Demerol ® )
- 177. Potentially inappropriate meds Beers et al. Updating the Beers Criteria for Potentially Inappropriate Medicuation Use in older adults Arc Intern Med 2003;136:2716-24 Potentially Inappropriate Safer alternatives Promethazine (Phenergan ® ) Prochlorperazine (Compazine ® ) Trimethobenzamide (Tigan ® ) Metoclopramide (Reglan ® ) Methyldopa (Aldomet ® ) Diuretics Diphenhydramine (Benadryl ® ) Loratidine (Claritin ® ), Fexofenadine (Allegra ® ) Indomethacin (Indocin ® ) Celecoxib (Celebrex) Chlordiazepoxide (Librium ® ) and Diazepam (Valium ® ) Lorazepam (Ativan) Amitriptyline (Elavil) – for depression SSRIs Fluoxetine (Prozac ® ) Sertraline (Zoloft ® ), Citalopram (Celexa ® ), Mirtazepine (Remeron ® )
- 178. Potentially inappropriate meds Beers et al. Updating the Beers Criteria for Potentially Inappropriate Medicuation Use in older adults Arc Intern Med 2003;136:2716-24 Potentially Inappropriate Safer alternatives Meperidine (Demerol ® ) Morphine Propoxyphene (Darvocet ® ) Percocet ® Diphenhydramine –for sleep Zolpidem (Ambien ® ) Diphenhydramine (Benadryl ® ) Loratidine (Claritin ® ), Fexofenadine (Allegra ® ) NSAIDs for arthritis Acetaminophen (Tylenol ® ) NSAIDs for gout Celecoxib (Celebrex ® )
- 186. Pager: 404-356-3729 Office: 404-605-2632 Cell: 404-788-2513
- 187. Elder Abuse and Neglect Dealing with this Difficult Topic when Patient is in the Hospital See PH Policy 2036
- 190. What is YOUR Responsibility? What do You do next?
- 192. Do you know whom you should contact? Who is the person on your floor to whom you would report your suspicions?
- 199. Why Emergency Dept Nursing??? Can this work? Older patients in the ED.
- 200. Not designed for older people Medical approach: 1 problem fixes symptoms Have a “story to tell” Geriatric approach: look for all contributing causes ED
- 205. Putting IT All Together Geriatrics in ED Nursing Drives Excellence
Editor's Notes
- 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
- Older are more emergent cases Over 20% after ED vs have decrease in ability to care for themselves- get meds, food/meals, manage f/u appointments
- fast, loud, Difficulty hearing / understanding Flow not conducive to older pt telling his story- has more history- intertwined
- Older adults there are usually mx issues that need to be addressed to prevent re-visit / adm Vague, nonspecific, ambiguous symptoms Often atypical presentations
- Evidence based, appropriate for ED setting; look at their presentation in context of functionality and physiology; Look for CAUSES and evaluate Talk about geriatric assessment
- 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&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.
- 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 Reduced ability to concentrate; less response to volume depletion, decreased elimination of certain drugs
- 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
- 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 Decreased max hr, less efficient response to stress, incresaed likelihood of orthostatic hypotension
- 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.
- 30-40% of cognitive deficit pt missed in ED, not part of nl assessment and pts present well in basic conversation
- Delirium- medical emergency; Benefit of standard reliable tools- communication between professionals, comparison of results,
- 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
- 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&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%. Record- report 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?
- These instructions can be repeated, but no additional instructions should be given. If the patient cannot complete the clock drawing test in ≤3 min, move on to the next step
- Affected by pain, sleep deprivation, pain meds, anxiety Snap shot of how they are doing with you RIGHT NOW in ED
- Measures individual’s reality orientation, registration abilities, attention and calculation skills, recall, language, and visuoconstruction (seeing and copying designs) Highest possible score: 30 points. Score of less than 24 needs further eval for possible AD or other dementia, depression, delirium, other psych disorder Those who score 20 or less generally have 1 of these disorders Is a screen not a diagnosis CAN CONSULT for help
- Older white males have highest risk of suicide 14% of older adults have depression Tell more by behaviors in older adults than by answers
- CAM- discuss with MD, pharmacist, family- any new meds, S&S infection etc MiniCog: fail- look at supports in home for activities this would affect even for short time
- Same as Minicog If fail executive function important to know who manages meds!!!!!!! Depression screen after score- note observations to support or not this score “ scored 5/15 but overall affect is vibrant and she is grateful to be alive;
- Observe mobility Katz scale- independent dependent, Decline in order listed; decline can be acute or chronic Verify the adls, iadls
- Tinetti
- Katz scale- Elements of self care Inability to independently perform even one may indiacte a need for suportive services Acute or chronic decline OT referral;independent dependent, Verify the adls, iadls;Independent with difficulty IADLS- higher level skills for living independent
- Katz scale- Elements of self care Inability to independently perform even one may indiacte a need for suportive services Acute or chronic decline OT referral;independent dependent, Verify the adls, iadls;Independent with difficulty IADLS- higher level skills for living independent
- Chart what you observed
- During skills time will have chance to practice the tools, and talk about how can integrate these into your practice
- selection process creates a problem for the patient at risk for pressure ulcer development who may not require immediate care. This disconnect could delay recognition, assessment, and communication about the potential for pressure ulcer development.
- ( dm neuropathy, phantom limb pain, trigeminal neuralgia, post herpetic , CVA, chemical CA
- blood pressure is often mistaken for undiagnosed hypertension. Increased heart rate is due to changes in the release of serotonin and endorphins as well as anxiety. Combination can cause decreased perfusion and can lead to increased fatigue for the older adult. Depression- suicide ideation Depletion syndrome: characterized by decreased levels of serotonin and endorphins
- Goal- max function and QOL Preventive approach- use less med: round clock, pre medicate Dementia: situation where you suspect may have pain- do clinical trial of pain med and non pharmacological stategies
- In addition to more typical- grimacing, splinting holding, rubbing Facial expressions most sensitive indicator
- Bone pain- tylenol, advil WHO Rarely see these issues occur with opioids used for pain control and even more rarely in older adults Addisiton Rarely occur with opioids used for pain control and even more rarely in older adults Antiemetics may be needed early on with the initiation of opioid therapy. preventive precautions are often recommended, such as the use of an assistive device. Falls, dizziness, and gait disturbances are not uncommon; therefore, Eventually, for most patients, the analgesic effect of opioids is preserved while tolerance develops to most side effects (eg, respiratory depression, sedation, nausea, and vomiting). 1 , 4 , 10 , 20 However, because tolerance does not develop to gastric hypomotility, patients need to take stool softeners for as long as they are on opioid therapy. Chewing or crushing sustained-release opioids must be avoided as doing so can cause rapid absorption of the entire dose resulting in overdosing Transdermal fentanyl should also be used with extreme caution in the elderly. It has a variable absorption rate in older adults and a long half-life even when the patch is removed. Transdermal fentanyl is contraindicated in opioid-naïve patients Tramadol hydrochloride, an analgesic that has some opioid properties and is used for mild to moderate pain, should be used with caution in the elderly because it may cause dizziness and reduce the seizure threshold. 22
- Avoid Demerol meperidine- ineffective or have high SE risks- CNS confusion
- Note that even when talking about health literacy the AMA cannot resist using language that would be difficult for someone with low literacy to be able to understand.
- They did do a little better in narrowing it down for their definition.
- The need for today’s patients to be more health literate is greater than ever, because medical care has grown increasingly complex. We treat out patients with an ever-increasing array of medications, and we ask them to undertake more and more complicated self-care regimens.
- A limited ability to read and understand information translates into poor health outcomes. Most Clinicians are surprised to learn that literacy is the single best predictor of health status. In fact, all of the studies that have investigated the issue report that literacy skills are a stronger predictor of an individual’s health status than age, income, employment status, education levels, and racial or ethnic group.
- Recent studies have shown that almost half of the US population lacks sufficient general literacy to effectively undertake and execute medical treatments and preventive healthcare it needs. Inadequate health literacy affects all segments of the population, although it is more common in the elderly, poor, minorities, and recent immigrants to the United States. Low Health Literacy cost the United States between $50 Billion and $73 Billion a year.
- Elderly – Limited Health literacy rates for those over 65 are estimated at 59% of the population, well over half.
- Mr. Day – Believes hypertension refers to a behavioral problem Mrs. Cordell – Signed procedure paperwork and only realized after the fact that she had consented to a hysterectomy Mr. Bell – Scared someone is going to realize his low literacy and often becomes angry or storms out of the doctor’s office Mrs. Grigar – Unable to fill out a form Mrs. Tilsey – Medication review “brown bag” where doctor asks what each medicine is for and how patient takes it Mrs. Grigar again – MD explaining arthritis is a way that she could understand
- When a patient brings in their medication, review the medications with the patient. Note if the patient opens the bottle and looks at the medication or do they identify their medication by reading the label? Be aware that some patients memorize the label and directions so probe further by asking when did they take the medication last and before that. If they looked confused, suspect the patient memorized.
- Are You Thinking What I’m Thinking? Liability?
- According to research from the American Tort Reform Association, Attorneys estimate that a clinician’s communication style and attitude are major factors in nearly 75% of malpractice suits. The most frequently identified communication errors are inadequate explanations of diagnosis or treatment and communicating in such a way that the patients feel their concerns are being ignored.
- Create a Shame Free Environment Slow Down: Communication is improved by speaking slowly, particularly with older adults who may have a harder time hearing the separation between words Use Plain, Non-medical Language - “Layman's Term” Show or Draw Pictures Limit the Amount of Information and Repeat It Use the Teach-Back or Show-Me Technique Ask Me 3 What is my main problem? What do I need to do about it? Why is it important for me to do this?
- Provide an example such as telling the patient with CHF to weigh themselves daily, and ask them to provide information back to you.
- Wouldn’t this be a nice thing to hear that a patient said to someone about you?
- 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
- Falls, confusion / AMS Instability / dizziness Functional Impairment / malaise
- Not just an injury Some of underlying issues- if not attended to- will cause revisit or admission not to mention increased linness for older adult
- Atypical- MI, acute abdomen Infection- uti uri, pneumonia, sepsis, sinusitis Drugs- polyphramacy, mismanagement meds, dehydration, CV Cns parkinsons, cva, tia, nph
- Decline in sight and hearing can have significant impact on older adult’s fall risk Have wider base, less arm swing, center of balance changes to name a few- All together- Not able to catch self when stumble as you did when you were younger
- Without adequate nutrition begin to lose strength, affecting mobility, safety Any issue with these systems can result in older adult trying to hurry- leading to higher risk of falls Depression- either under-treated or undiagnosed can impact safe mobility People with dementia lose ability to identify risk situations This can be chronic or acute issue that can result in a fall. So moving on to acute illnesses…………………….
- These are a few categories of drugs that can increase an older pts fall risk. Certainly there are many more- the idea here is we actively contribute to increasing their risk. So what prevention can we offer our pts?
- Ortho for dizziness, dehydration measure
- Communicate with ED MD, family, staff on unit if admitted, facilities if returning, PCP PT eval and tx, assess for aids, exercise, safety check of home, use of aids RN for meds management, nutrition Sixty Plus for case management Family- for increased oversight, to include in teaching, verify information
- Logically include sensory decline PD
- 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.
- Delirium comes on over hours to days- Due to inability to maintain homeostasis when confronted with acute illness, medication adverse reaction- more at risk than other ages but can happen at any age May come to ED with delirium, or may begin to be obvious there, or may be prevented in ED 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
- Prior to illness- caregiver, facility staff, family, friends Do entire geriatric assessment- often find mix of the 3 D’s- don’t stop because found 1 cause Specific behaviors Avoid general terms i.e. confusion, disoriented Alert vs attentive Medical emergency- need to identify cause and correct- can regain all function 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-
- Watch labs, record I&O and food intake; encourage 1500 ml as minimum; check orthostatic BP Eval where they are and support; be sure they are using sensory aids- if they do not have, adjust environment: no glasses- put everything close at hands, no hearing aid- use pocket talker or stethescope to help them hear Clocks, calendars, white boards; 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.
- 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 Proactively address- nutrition, hydration, skin breakdown, blood clots ( immobility), mobility and deconditioning / loss of function, use sensory aids,
- 50% never diagnosed and treated Most treated are treated inappropriately Alzheimers: most common 70%; tangles and plaques turns into severe cognitive dysfunction as well as behavior and personality changes and, eventually, loss of physical function Vascular, lewey bodies, parkinson’s: sl differences but end result same other conditions that may cause similar symptoms, such as stroke, hypothyroidism, depression, nutritional deficiency, brain tumor, Parkinson’s Disease, or inappropriate medication
- Often family has not picked up on changes; pt presents well on phone conversations-confabulates; At home they have patterns- not have to process- in new environment processing continuously- very stressed
- If has dx of dementia, mini cog, mmse can help identify abilities during ED visit MMSE can just frustrate pt with dementia
- May not remember directions given in ED, not reliable historian- need verify-get info from someone else; health instructions need to include someone who can help pt; would not discharge on his own Clock- executive function- managing meds, safety issues, finances- needs over sight Much dementia is not dx- denial etc Families need to have information so they can plan ahead- possible work with pt while they still able to make decisions
- At end of life, pts partly or completely bedfast. Death comes mostoften in the forms of aspiration PNA. Unable to swallow properly, the pt breathes food or liquids into the lungs
- Avoid complexity it creates confusion and anxiety Changes in medications, nutrition, therapy, personnel, or location
- Agitation: can be caused by need to urinate, as well as by depression, overstimulation Vocal outbursts, restlessness: Distract- Prompt pt to reminisce, touching pt, giving pt soft doll, stuffed animal, audiotapes of soothing sounds
- May not remember directions given in ED, not reliable historian- need verify-get info from someone else; health instructions need to include someone who can help pt; would not discharge on his own Clock- executive function- managing meds, safety issues, finances- needs over sight Much dementia is not dx- denial etc Families need to have information so they can plan ahead- possible work with pt while they still able to make decisions
- 60 million Americans greater than 65 yrs. Only 10% of these receive treatment Major public health problem – leading to impaired functional status, increased mortality, and excessive use of healthcare resources.
- Many theories Chemicals depleted by stress- physical ( ACUTE CHRONIC ILLENSSES) or emotional- losses of aging
- or pleasure in activities previously enjoyed, personal appearance- self care 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.
- 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. Biggest risk is number of losses as age- value, income, home, friends, family, spouse, social position etc chemical
- Pt needs further evaluation for diagnosis. Indicates pt may not attend to instructions, plan of care, fill prescriptions after discharge without prompting- requires f/u in community and additional oversight Could be situational- needs to be watched for
- Pt needs further evaluation for diagnosis. Indicates pt may not attend to instructions, plan of care, fill prescriptions after discharge without prompting- requires f/u in community and additional oversight
- Nutrition- oral causes, labs- alb, prealb, cholesterol; swallowissues, functional ability, social issues 85-year-old woman with a three-month history of intermittent abdominal pain, nausea, diarrhea, and gradual weight loss, had been living independently in a mobile home park. Her daughter, who lived nearby, brought the woman home for some meals and prepared leftovers and meals for her to warm in the conventional or microwave oven when she was alone. The initial medical examination showed no underlying cause for the weight loss and abdominal symptoms. The patient was given medication for the abdominal discomfort and was encouraged to add over-the-counter nutritional supplements to her daily diet, yet the patient's condition continued to decline. A referral to the Kaiser Permanente (KP) case management program for the frail elderly led to a home visit--and to a revelation about the abdominal symptoms: The case manager discovered that the elderly woman's refrigerator was noisy and had been disturbing her sleep. The woman had attempted to address this problem by unplugging the refrigerator each evening at 8 pm when she prepared for bed. When informed of this situation, the family replaced the refrigerator, and the abdominal symptoms and weight loss subsided.
- Don’t stop looking after find 1 Geriatric Assessmentwill keep from missing and covers lot of causes
- In ED – How many of your patients each day are older adults in the ED? Typically, when asked staff says 40% or so, but studies suggest the number is closer to 20%. Why the difference? (comorbidities, may take longer to triage or work up, more fequently admitted, can be frustrating, etc.) Have you faced a situation where the patient or the caregiver didn't follow or forgot the discharge instructions that you gave them? Do people seem careless and oblivious to those important facts and guidelines that you share with them in the form of instructions at the time of discharge The situations where we see patients, is stressful, anxiety ridden and short- pts are more ill. The directions may be foreign in nature or complicated- or not. Results in confusion, dis-satisfaction, concern that the info was not “gotten” - both for pt / families and nursing staff . Have to repeat information, phone calls after they’ve left Striving to provide discharge information in clear, efficient manner that maximizes the older pts ability to comprehend and function with it
- As Dee mentioned first thing this morning, older adult patients who are seen in the ED are more likely to be admitted or revisit the ED. Statistics show that 27%, or more than 1 in every 4 older adult patients treated in the ED, will revisit the ED, be hospitalized, or die within 3 months. Delirium – Present in 10% of elderly patients but only recognized in 35%. Missing this diagnosis may mean missing an underlying medical condition. That places these patients at a higher risk for bad outcomes. Discharge planning for older patients is highly involved and time consuming.
- Transitions means when sending a patient into the hospital, back to a facility, or returning them home.
- Michelle has already addressed some of this with you earlier today. And it is great that we area assessing these areas, but then the important question becomes what do we do with this information: You assess the person has memory loss and lives alone, do you give them the discharge instructions and send them home in a taxi? You know the person is a fall risk and uses a walker, but the doctor has put their arm in a sling, what do you do? It may mean that we need to get durable medical equipment for a patient. Items such as a cane, walker, bedside commode, or shower chair are very common needs for older adults. How are we doing this currently in the ED? It may also require a request for home health services to follow up with the patient in their homes. Let’s look at some of the reasons home health may be ordered for a patient.
- Andy More has already touched on some of these items earlier today when discussing health literacy, but they’re important to remember. Language - Medical terms (myocardial infarction), as well as foreign language Avoid technical terms Use specifics Employ active verbs Their interpretation depends upon their background, their language, and their experience with the medical system. Instructions are also open to interpretation : Ask them to repeat the instructions and the sequence of steps that you outlined. (in their own words; ex: how would you do this at home?) This will not only create confidence about the usefulness of the instructions but also make them comfortable in using the instructions. This is called the TEACH BACK method. Hearing - You must remember that if you are trying to help someone read your lips, you need to talk slowly and normally. You may use a voice amplifier if required or a stethoscope in your patient’s ears if you choose to. Some of your patients may come with a hearing aid. Make sure that it is properly installed and working before proceeding with the teaching. Visual- Highlight:When you introduce a new topic, always underline or bold the headers. To highlight important information, indent the text or put it in a text box. Pictures or visuals are great tools for emphasizing important points and making it easier for the patient to understand the instructions. They also break up the text and help hold the patient's attention. SIZE of font Arrangement- white space, ragged edge; Try to include as much white space as you can and keep the spacing at 25 to 30% of the font size. For good readability, the paper-to-print contrast should be 70:30 Memory- Remember that it’s going to take you longer to teach older patients. The slower processing of messages and slower responses add to the memory problems in older patients. Thus you may want to start teaching early to give your patients adequate time to learn and process your instructions. You also need to write more detailed instructions for them to review. Some older adults may take medications that could create or induce forgetfulness. If you want older patients to learn their discharge instructions correctly, the best method will be to present them with real-life scenarios that they can relate to and write down everything they need to remember. KISS
- We’re going to talk in a few minutes about the Care Transitions intervention and how it addresses discharge instructions, but let’s just touch now on what it is and why we do it. adequate and appropriate useful and critical information about resources inform them about the health problem they are facing, what they need to do to take care of it at home, and advise them regarding options they have. Mandatory- essential part of compliance with regulatory and patient health care standards.
- Have you noticed there are so many things you need to tell your patients or their caregivers at one time? How many things do you think we can remember at a time? 3 In a nutshell, you need to adjust the teaching material based on audience age, barriers to learning, medical literacy, and cultural beliefs. You may ask yourself, "What is the least amount of information I must include that will motivate behavior change and action?" You should only give your patients and their families as much information they need or want to know. Providing all the information you know on the subject will not serve any purpose.
- For a patient to be appropriate for home health, he or she must be considered homebound, or at least must face hardship in order to get out of the home. Probably the most clear cut example of home health needs is when physical therapy or occupational therapy is indicated. When these therapists are in the home, they will often conduct a home safety inspection for the patient as well in order to minimize the risks of falls. An order can be placed for “skilled observation and assessment” to allow a nurse to do medication reconciliation and teaching with the patient and/or their caregivers.
- As long as a skilled service is in place in the home, the patient can receive additional services as well, such as a home health aide to assist with personal care and a medical social worker . Home health nurses are no longer able to go to the patient’s home only to draw labs. In order to do this, they have to be seeing the patient for some other reason as well. When in question, you do have resources available to you. You can always ask myself (ext 1954) or Lakia Porche (ext. 3486).
- KISS
- Why?? What brought you to ED as area Rapid triage, diagnosis multiple comorbidities, polypharmacy, subtle S&S, “story to tell”
- Rapid triage, diagnosis Environment is unfriendly, intimidating: stretcher, floors- slippery/fall risk, no windows- difficult for orientation, noise / bustle- problem hearing, relaxing; reflect the tone of environment multiple comorbidities, polypharmacy, subtle S&S, “story to tell”
- Modify aspects of speech in response to evaluation of person speaking to, level of competence Over accommodation- simpler vocabulary, high pitched tone, slower speech, exaggerated emphasis on certain words; found in hospitals, NH- using child like language, being abrupt, disrespectful, disinterested, ignoring while talking to others Use of first names, terms of endearment ( adult speaking to child learning language Study of 12 physicians: more abrupt and showed greater disinterest, blocked communication with older pts
- Who tell you she ‘s new resident- had cva and was dc’d from your hospital 3 wks ago Nurse says that she is a new resident of the NH She came from your hospital three weeks ago after recovering from a stroke. The doctor on call hasn't seen her before and wanted her transferred to the ED because of his concern about a possible new stroke. Worsening weakness has been developing during the past week. She has stumbled and fallen three times in the past week Information not specific or include baseline prior to admission: need timeframe, ADLs
- When outlined systematically, this change is not subtle. Two features suggest that it is not consistent with progression of aging or with chronic dementia. The progression of functionaI decline with aging is generally apparent over the course of several months or years. The "normal" sequence of functional loss is from bathing to feeding, with bathing first to be lost and feeding last. The time course of decline in this case is rapid, I week. Mrs. Henson has trouble with several ADLs at once: the higher end of the spectrum, dressing, and the lower, feeding. The full review of systems should be repeated with the nursing home nurse because the patient may not give an accurate history. Mrs. Henson seems to be a denier with imperfect recall.
- The nurse relates the following additional information regarding the reasons for transfer: Mrs. Henson has not felt well for about a week. She's complained of being tired. She's gone to bed early and stayed in bed until asked to get up. For the past 4 days she hasn't been able to button her buttons. Three times in the past week, including today, she was found on the floor, trying to get up. She was awake with no injury except bruises at the knees and elbows. She's been eating less, and today she didn't eat anything except her juice and pills.
- Was in hospital 3 wks ago- may need to consider hospital acquired pathogens Previous CVA may put at risk for aspiration- pneumonia Recent incontinence- could be sign of UTI
- . Elderly patients may have asymptomatic bacteria and pyuria that does not require treatment However, in the setting of rapid functional decline and new incontinence, the presence of pyuria should be considered significant The presence of pyuria (>10 WBC/ml of spun urine) is a sensitive though not specific predictor of the presence of bacteriuria. Most(94%) persons with >100,000 CFU/ml will have pyuria."* cNeed to observe improvement after tx of MEDICAL illness