Transcript Analysis of Geriatric Care Needs

ANALYSIS OF GERIATRIC CARE
NEEDS
Lorinda K Greer
Ferris State University
Nurs 314 Gerontological Nursing
ANALYSIS OF GERIATRIC CARE NEEDS
INTRODUCTION
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Eileen is 86 years old, widowed and lives
independently in her older 2-story home
History: osteoarthritis, hypertension, CHF,
GERD, and bilateral hip replacements
Medications: Vicodin for pain, Coreg for her CHF,
lisinipril for her HTN, and prevacid for her
GERD.
INTRODUCTION CONTINUED
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Able to care for self, do own laundry and cook
meals
Family assists with heavy cleaning and home
repairs
Because she has never driven, she depends on
her family to take her shopping and to her
doctor’s appointments.
Uses wheeled-walker for ambulation
INTRODUCTION CONTINUED
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Eileen is on a fixed income, receiving Social
Security and Medicare benefits
Family has been encouraging her to move from
her large, older home into a smaller apartment or
retirement community
Eileen is determined to stay in her home and
does not want to move
ASSESSMENT : TOOLS
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Fulmer SPICES
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Numeric rating scale (NRS)
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Geriatric Depression Scale
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Lawton’s Instrumental Activities of Daily Living
ASSESSMENT: FULME’R SPICES
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S = Sleep disorders
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P= Problems with eating or feeding
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I= Incontince
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C= Confusion
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E= Evidence of falls
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S= Skin Problems
ASSESSMENT: FULMER’S SPICES
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“SPICES” is an “effective instrument for
obtaining the information necessary to prevent
health alterations in the older adult patient,”
(Wallace & Fulmer, 2007).
Eileen denies problems with eating or feeding,
incontinence, confusion, evidence of falls, and
skin breakdown.
However, sleeping has always been an issue for
her, especially falling asleep
ASSESSMENT: FULMER’S SPICES
Difficulty falling asleep
 Usually is up late due to restlessness
 Falls asleep well after three o’clock in the
morning
 Wakes up after ten in the morning.
 Naps regularly in the afternoon for two to three
hours a day
 Tries to go to bed early, but has trouble getting to
sleep.
 Reports the Vicodin for OA helps her sleep better
at night
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ASSESSMENT: NUMERIC RATING SCALE
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Pain is assessed by rating pain on a 0 to 10 scale
with 0 meaning no pain and 10 the worse pain
ever (Flaherty, 2008)
Further interpreted as 1 to 3 being mild pain, 4
to 6 representing moderate pain, and 7 to 10
signifying severe pain (Flaherty, 2008)
Eileen rated her pain as a “5”, meaning moderate
pain
ASSESSMENT: GERIATRIC DEPRESSION SCALE
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The GDS is a short 15 question yes/no
questionnaire used to assess mood and can
provide insight as to whether a more in depth
assessment is necessary (Greenberg, 2007)
Eileen scored 2 out of 15, preferring to stay at
home, rather than going out and doing new
things and not feeling full of energy
If she answered honestly, her score was less than
5, therefore no indication for depression
ASSESSMENT: LAWTON’S INSTRUMENTAL
ACTIVITIES OF DAILY LIVING SCALE
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Lawton’s IADL scale “assesses a person's ability
to perform tasks such as using a telephone, doing
laundry, and handling finances,” (Graf, 2008)
She scored “0” for shopping and driving, because
she does not drive and has not for many years
She scored a “1” for using the telephone, food
preparation, cleaning, laundry, medications, and
finances
Total score= 6 out of 8
CULTURAL CONSIDERATIONS
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European American values include, “individualism,
autonomy, future orientation, and mastery of the
environment (Omizo, Kim, & Abel, 2008)
Eileen is of European decent and is able to trace her
ancestry to the Mayflower
She is independent and has an unwavering commitment to
stay in her home.
She does not regularly attend church, but has a strong
spiritual life
Reading her Bible and praying every day.
BIOLOGICAL THEORIES OF AGING:
THE
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GENE/BIOLOGICAL CLOCK THEORY
The Gene/Biological Clock Theory suggests
genetic predisposition affects the aging process
(Grossman &Lange, 2006).
Eileen’s mother suffered from high blood
pressure and arthritis which may be contributing
factors to her CHF and OA.
BIOLOGICAL THEORIES OF AGING:
THE FREE RADICAL THEORY
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The Free Radical Theory is characterized as, “end
products accelerate oxidative metabolism, and
react with proteins, lipids, and ribonucleic acid
(RNA) to cause cell damage leading to diseases
such as diabetes and arthritis, gene modulation,
lipid peroxidation, and accelerated aging,”
(Grossman & Lange, 2006).
Based on this theory, Eileen’s heart failure and
osteoarthritis may be caused by oxidative
damage to her cells.
NURSING DIAGNOSES
Chronic pain related to osteoarthritis, as
evidenced by Eileen’s pain rating of “5” on the
numeric rating scale, sleep difficulties, and facial
expressions (Cox et al., 1993).
 Sleep pattern disturbance related to chronic pain
and restlessness, as evidenced by Eileen’s verbal
complaints of difficulty falling to sleep (Cox et al.,
1993).
 Impaired physical mobility related to pain and
musculoskeletal impairment from her OA, as
evidenced by decreased muscle strength (Cox et
al., 1993).
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PLANNING
Eileen will maintain a tolerable level of pain by
April 20.
 She will verbalize a pain rating less than “3”
according to the NRS by April 25.
 Eileen to report falling asleep before midnight by
April 30.
 She will express decreased number of complaints
of being unable to fall asleep by May 15.
 Exhibiting the ability to perform active range of
motion and muscle strengthening exercises by
May 20.
 She will also show improved muscle strength and
endurance while ambulating by June 1.
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IMPLEMENTATION
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Interventions addressing her chronic pain should be the first priority.
“Pain will compromise one’s quality of health, it will affect both
mental and physical functioning,” (Ebersole, Hess, Touhy, Jett &
Luggen, 2008, p. 282).
Eileen will explore what activities exacerbate her pain and what
times of day her pain levels increase.
Based on this information, a pain medication schedule will be
developed and adhered to for optimal pain control.
To better understand her pain, she will learn the concepts of rating
pain, utilizing the numeric rating scale.
Eileen will learn alternative pain therapies, including heat therapy,
distraction and relaxation techniques.
Because she is active spiritually, prayer and meditation could be
incorporated to help alleviate pain.
Distraction through music and rhythmic breathing may be useful by
allowing one’s mind to concentrate on something other than pain,
including pain from osteoarthritis (Ebersole, Hess, Toughy, Jett &
Luggen, 2008, p. 289).
IMPLEMENTATION CONTINUED
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Relaxation techniques learned for pain management
such as meditation, rhythmic breathing, music and
prayer will also be implemented prior to bedtime to
help Eileen fall asleep.
She will also monitor her pain level using the NRS
prior to bedtime and take prescribed pain medication.
Eileen will also demonstrate sleep preparation
activities such as eating a high carbohydrate snack,
having a warm drink, and creating a calm sleep
environment.
According to the Hartford Institute, “every effort
must be made to create a good sleep environment for
older adults,” (Fulmer, 2007).
IMPLEMENTATION CONTINUED
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Interventions regarding impaired mobility have also
been added to Eileen’s plan of care.
She will learn active range of motion exercises to
increase muscle tone.
Regular exercise promotes joint flexibility, improves
function and coordination, increases energy, and
reduces pain (Ebersole, Hess, Touhy, Jett & Luggen,
2008, p. 391).
Eileen will monitor her pain level before engaging in
activity and take prescribed medication as needed.
She will maintain appropriate fluid levels and diet
with adequate amounts of protein.
Proper protein intake has been associated with
retaining muscle (Benefield & Higbee, 2007).
While engaging in activity, Eileen will also rest in
between periods of activity.
EVALUATION: TEACH-BACK METHOD
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The teach-back method will be used to evaluate
Eileen’s understanding of the plan of care
Allow for discussion and clarification if she does
not understand what she has learned.
Ensure she is successful utilizing her new skills.
She will repeat what she was taught regarding
exercises, relaxation exercises, and the numeric
rating scale for pain, using her own words
(Cornett, 2009).
EVALUATION CONTINUED
By the end of the month Eileen should verbalize
improved pain control by implementing a pain
schedule and demonstrating relaxation
techniques.
 She will also report improved sleep with the help
of sleep routine including a bedtime snack, warm
beverage before bed and calm environment in 4
weeks.
 Eileen will demonstrate improved mobility and
endurance in 6 weeks.
 Within one month she will demonstrate the
ability to perform active range of motion
exercises and proper nutritional intake
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PUBLIC POLICY PROPOSAL
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Despite her family’s protests, Eileen wants to
remain in her own home.
She lives in a home older than 100 years which
requires a lot of maintenance and upkeep.
As she ages, her home also becomes a safety
concern.
PUBLIC POLICY PROPOSAL
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A concern for Eileen regarding possible public policy
change relates to her living independently in an older
home.
If an elderly person is receiving social security and
Medicare benefits, a program needs to be in place to
evaluate the home for safety and efficiency.
The Aging report states, “we must make it easier for less
wealthy older homeowners to occupy more supportive
housing arrangements by assisting them with their moving
plans and by better informing them and the professionals
who serve them about their benefits,” (Golant, 2009).
The program should not force the elderly from their homes,
however, offer support, education and alternatives to living
in a home that may be difficult to sustain.
Additionally, the program could offer incentives to the
homeowners who decide to down-size and seek alternative
housing options.
CONCLUSION
The assessment of Eileen reveals she is quite
healthy.
 Chronic pain from osteoarthritis affects her
overall wellbeing, including sleep and physical
mobility.
 Developing a plan of care with measurable goals
and collaborative interventions will allow her to
remain independent.
 At the same time, public policy changes
pertaining to elderly persons living in older
homes must be explored to empower and support
clients to make affordable and safe housing
decisions.
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REFERENCES
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Benefield, L.E. & Higbee, R.L. (2007). Frailty and its implications
for care. Hartford Institute or Geriatric Nursing.
ConsultGeriRN.org.
Cornett, S. (2009). Assessing and addressing health literacy. The
Online Journal of Issues in Nursing, 14(3).
Cox, H.C., Hinz, M.D., Lubno, M.A., Newfield, S.A., Ridenour,
N.A., Slater, M. M., &
Sridaromont, K.L. (1993). Clinical Applications of Nursing
Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and
Home Health Considerations (3rd ed.). Philadelphia: F.A.
Davis Company.
Ebersole P., Hess, P., Touhy, T., Jett, K., & Luggen, A. S. (2008).
Toward healthy aging: human
needs and nursing r
esponse. St. Louis: Mosby.
Flaherty, E. (2008). How to try this: using pain-rating scales with
older adults. AmericanJournal of Nursing, 108(6), p. 40-47.
REFERENCES
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Fulmer, T. (2007). How to try this: Fulmer SPICES.
American Journal of Nursing, 107(10), p. 40-48.
http://www.nursingcenter.com/prodev/cearticle.asp?ti
d = 742423.
Geriatric Depression Scale. Retreived from:
http://www.stanford.edu/~yesavage/GDS.html
Golant, S.M. (2009). Aging in place solutions for older
Americans: Groupthink responsesnot always in their
best interest. Public Policy and Aging Report, 19(1).
Graf, C. (2008). How to try this: The Lawton Instrumental
Activities of Daily Living Scale.American Journal of
Nursing, 108(4), p. 52-62.
Greenberg, S.A. (2007). How to try this: The Geriatric
Depression Scale: short form. AmericanJournal of
Nursing, 107(10), p. 60-69.
REFERENCES
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Grossman, S. & Lange, J. (2006). Theories of aging as
basis for assessment. MedSurg Nursing, 15(2),
p. 77-83.
Lawton, M.P., & Brody, E.M. (1969) Assessment of
older people: Self-maintaining and instrumental
activities of daily living. Gerontologist, 9, p. 179186.
Omizo, M.M., B.S., Kim, & N.R. Abel. (2008). Asian
and European American cultural values,
bicultural competence, and attitudes toward
seeking professional psychological help among
Asian American adolescents. Journal of
Multicultural Counseling and Development,
36(1), p.15-28.