Transcript 187c221eedad66e

Assessment and Management
of highly dependent patients
prepared
by
Salwa Mahmoud Abd elwahab
Under supervision
Pr.Dr Kamilia Fouad
Professor of medical surgical nursing
Faculty of nursing
Ain Shams university
2010
OUTLINES:
 Introduction
 Definition of highly dependent patients
 Definition related to highly dependent patients
 Chronic illness
 Disability
 Impairment
 Functional limitations
 Activities of daily living
 Instrumental activities of daily living
 Rehabilitation
 Adaptation
Outline cont
Classification of dependent patients
Partial [temporary] dependent patients
 Complete [permanent] dependent patients
 Interdisciplinary team.
Physicians
 Nurses
 Physiotherapist
 Occupational therapist
 Speech therapist
 Nutritionist dietitian
 Speech therapist
 Nutritionist dietitian
 Social workers
 Psychologists
 The recreational therapist
 The patient’s spiritual leader
Nursing care plan :
Assessment
Functional assessment
Interview
Health history taking
Physical examination [from the head to toes]
Physical assessment [all the body
systems]
 Nursing diagnosis :
Physical problems [actual and potential]
 Psychosocial problems [actual and potential]
 Planning
 Implementation
 Evaluation
Objectives :
Define highly dependent patients
Define [key terms] related to highly dependent
patients
Enumerate the etiological chronic
Compare between two types of dependent patient
Identify interdisciplinary team
Describe factors that must be taken in nurse’s
consideration when providing care for highly dependent
patient
Identify assessment tools used for a highly
dependent patients
Objectives cont :

List three major nursing diagnosis for highly
dependent patients
 Implement nursing intervention to provide
quality care for highly dependent patients
 State several ways to evaluate whether or not
intervention outcomes have been met
Definition of highly dependent patient
It is a state in which the individual
experiences a limitation of activities for
independent physical movement or when
the person’s movement is restricted for
medical reasons, result in secondary
disabilities, these disabilities may develop
in one or several body systems.
Definition related to highly
dependent patients
 Disability
:
The
World
Health
Organization(2008) defines Disability as
follows: "Disabilities is an umbrella term,
covering impairments, activity limitations,
and participation restrictions.
 Disabilities include : Sensory impairments
(particularly hearing and vision) physical
mobility impairments (from injury, chronic
illness, congenital defect, or psychiatric
conditions), emotional/cognitive impairments.
Impairment : Is the physical or physiological
cause of the limitation, whether related to
disease, trauma, or birth defect that may or
may not be associated with limitations. For
example, a person with a visual impairment
may have the limitation of needing to wear
glasses.
Activities of daily living: Are the basic
activities usually performed in the course of a
normal day in a person’s life, such as eating,
toileting, dressing, bathing, or brushing the
teeth.
Instrumental activities of daily living :are not
necessary for fundamental functioning, but they
let an individual live independently in a
community;(e.g)doing light housework
,preparing meals, taking medications, shopping
,using the telephone , using technology)
 Functional limitations : Refer to difficulties
people may experience in performing activities of
daily living (ADLs) or instrumental activities of
daily living (IADLs).
Adaptation :The dynamic process in which the
behavior and physiological mechanisms of an
individual continually change to adjust to
variations in living conditions.
 Rehabilitation : Is “the process of adaptation,
or recovery, through which an individual suffering
from a disabling condition, whether temporary or
irreversible, regains, or attempt to regain,
maximum function, independence, and
restoration. It should begin at the first day
a
person is diagnosed with a disorder that can
result or has resulted in functional limitation.
Disabilities or functional limitations which leading
to that the patient become highly dependent can
result from stable or progressive chronic illnesses,
this chronic illness include :
 Chronic illness e.g heart failure, End stage renal failure
 Musculoskeletal impairment
Postural abnormalities : Congenital acquired postural
abnormalities affect the efficiency of the musculoskeletal
system as well as body alignment balance and appearance.
Fracture of the : knee, hip, pelvis and spine.
 Neurological impairments:
 Damage to the central nervous system :
damage to any voluntary movement.
 Multiple sclerosis (neurological condition).
 Stroke.
Paralysis  hemiparalysis, or quadriparalysis
CLASSIFICATION
PATIENT
OF
DEPENDENT
 Temporary (partial) dependent patient
 Permanent (complete) dependent patient
INTERDISCIPLINARY TEAM
- An interdisciplinary team : Is a group of people
working together with the client to achieve goals for
recovery or adaptation.
This team include :
Nurse
Physician
 Physical therapist
Social worker
Psychologist
 Recreational therapist
 The nutritionist or dietitian
Occupational therapist
Speech language therapist
NURSING CARE PLAN
DEPENDENT PATIENTS
FOR
HIGHLY
General assessment :
When working with people highly dependent
patient, you need to have excellent assessment
skills. Although the entire interdisciplinary team
aids in holistically assessing the client, you as
a
nurse are primarily responsible for documentation
in several key areas.
The nurse will assess patients through:
 Functional assessment
 Interview& health history taken
 Physical examination [from the head to
toes]
 Physical assessment [all the body systems
 Psychosocial assessment.
Functional assessment of the highly
dependent patients :
The Barthel index as shown in table measures
the client’s mobility and self care status over
client’s status in terms of levels of
dependence or independence is rated in 10
categories of function. Each category is
assessed with nurses rating from 0:15. The
highest is 100 that mean the person is
content.
The Barthel index
Functional component
With help
Independent
5
10
5-10
15
3. Personal toilet (wash face, comb hair, shave, & clean teeth)
0
5
4. Getting on and off toilet (handling, clothes, wipe & flush)
5
10
5. Bathing self
0
5
6. Walking on level surface
10
15
7. Ascending and descending stairs
5
10
8. Dressing (includes tying shoes, fastening fasteners)
5
10
9. Controlling bowels
5
10
10. Controlling bladder
5
10
1. Feeding
2. Moving from wheelchair to bed and return (including sitting
up in bed)
Katz index of Activities of daily living :
From Katz, S., Ford, A.B., Moskowitz, R.W., Jackson, B.A., Jafe, M.W., & Cleveland, M.A. (2003): Studies of illness
in the aged. The index of ADL: A standardized measure of biological and psychosocial function. Journal of the
American Medical Association, 185 (12), 914-919.
Interview and history of the highly dependent
patients:
It is important for the nurse to get information from
the patient and other members of the team. The patient’s
age, condition and feeling will be great help in the
prevention of complication.
The question should be directed to gather information relate
to:
Personal data: Age, interest, type of activities encountered,
social set up and relationships.
 Dietary habits : Type of food, preparation, amount as this
would give an indication of the necessary needs of patient.
 Bowel habits : To help the patient cope with the new
situation and prevent complications associated with bowel
habits.
 Sleeping pattern : As well as most comfortable
position and the comfort measures used
usually.
 Recreational activities : Which are of most
interest to the patient in order to provide the
patient with activities that will prevent
boredom and introspection.
 Intake of drugs : Such as heparin that might
predispose to pressure sores.
Physical examination for the highly
dependent patient
System
Metabolic
Assessment
techniques
Abnormal findings
Inspection
Slowed wound healing, abnormal
laboratory data
Inspection
Muscle atrophy
Anthropometric
measurements (mid
upper arm
circumference, triceps
skin fold measurement)
Decreased amount of subcutaneous
fat
Respiratory Palpation
Inspection
General edema
Asymmetrical
chest
wall
movement, dyspnea, increased
respiratory rate
Cardiovascular
Auscultation
Crackles, wheezes
Auscultation
Orthostatic hypotension
Auscultation,
palpation
Increased heart rate, third heart sound,
weak peripheral pulses, peripheral edema
Musculoskeletal Inspection,
palpation
Decreases ROM, erythema,
diameter in calf or thigh
increased
Palpation
Joint contracture
Inspection
Activity intolerance, muscle atrophy, joint
contracture
Skin
Inspection,
palpation
Break in skin integrity
Elimination
Inspection
Decreased urine output, cloudy or
concentrated urine, decreased frequency
of bowel movements
Palpation
Distended bladder and abdomen
Auscultation
Decreased bowel sounds
Physical assessment [all the body
systems] :
The physical assessment of highly dependent patient
that may be identified during a nursing assessment
as the following:
Metabolic system :
 When assessing metabolic functioning, the
nurse uses anthropometric measurements
(measures of height, weight, and skinfold
thickness) to evaluate muscle atrophy.
 Assess fluid intake and output to determine
whether a fluid imbalance exists.
Monitoring laboratory data such as electrolytes,
serum protein (albumin and total protein) levels,
and blood urea nitrogen (BUN) aid the nurse in
determining metabolic functioning.
Monitoring food intake and elimination
patterns will help to determine altered
gastrointestinal functioning and potential
metabolic problems
The client’s food intake should be assessed
before the tray is removed to determine the
amount eaten.
Nutritional imbalances can be avoided if the
nurse assesses the client’s dietary patterns and
food preferences early .
Respiratory system
A respiratory assessment should be performed
at least every 2 hours for clients with restricted
activity.
 The nurse inspects chest wall movements
during the full inspiratory-expiratory cycle.
 If a client has an atelectatic area, chest
movement may be asymmetrical.
In addition, the nurse auscultates the entire
lung region to identify diminished breath sounds,
crackles, or wheezes.
 Auscultation should focus on the dependent
lung fields because pulmonary secretions tend to
collect in these lower regions.
A complete respiratory assessment identifies
the presence of secretions and can be used to
determine nursing interventions necessary for
optimal respiratory function.
Cardiovascular system :
Cardiovascular nursing assessment of highly
dependent patients includes: blood pressure
monitoring evaluation of apical and peripheral
pulses, and observation for signs of venous stasis
(e.g., edema and poor wound healing).
Edema may indicate the heart’s inability to
handle the increased workload.
The nurse assess the venous system, because
deep vein thrombosis is a hazard of restricted
mobility.
A dislodged thrombus, called an embolus, may
travel through the circulatory system to the lungs
or brain and impair circulation.
Musculoskeletal system :
Major musculoskeletal abnormalities that may be
identified during nursing assessment include:
Decreased muscle tone and strength.
Loss of muscle mass, and contractures.
Losses in muscle tone and muscle mass.
Muscle atrophy is a common complication that
arises from the lack of weight bearing found with
bed rest.
Assessment of ROM is important as a baseline
against which later measurements can be
compared to evaluate whether a loss in joint
mobility has occurred.
Integumentary system :
The nurse must continually assess the client’s
skin for breakdown and color changes such as
pallor or redness.
hygiene measures are performed, or elimination
needs are provided for. At a minimum,
assessment should occur every 2 hours.
−Elimination system :
The client’s elimination status should be
evaluated on each shift, and total intake and
output should be evaluated every 24 hours.
The nurse should determine that the client is
receiving the correct amount and type of fluids
orally or parenterally.
Inadequate intake and output or fluid and
electrolyte imbalance can increase the risk for
renal system impairment, ranging from recurrent
infections to kidney failure.
Dehydration can also increase the risk for skin
breakdown, thrombus formation, respiratory
infections, and constipation.
 Assessment of elimination status should also
include the adequacy of dietary choices and the
frequency and consistency of bowel movements.
 Accurate assessment enables the nurse to
intervene before constipation and fecal
impaction occur.
Psychosocial assessment :
Common reactions to restriction of activities
include boredom, feelings of isolation,
depression, and anger.
The nurse should observe for changes in
emotional status.
Because psychosocial changes usually occur
gradually, the nurse should observe the client’s
behavior on a daily basis.
Nursing diagnosis
Respiratory system ;
Risk for ineffective airway clearance.
Risk for ineffective breathing pattern.
Risk for impaired gas exchange
Cardiovascular system :
Activity intolerance related to increased
cardiac
workload.
Risk for thrombus information
Risk for Orthostatic hypotension
Metabolic system :
 Altered nutrition less than body requirement.
 Altered nutrition more than body requirement.
 Risk for fluid volume deficit.
Elimination system :
Altered urinary elimination.
Risk for constipation
Risk for renal calculi
Risk for urinary tract infection
Muscskeletal system
Impaired physical mobility.
Activity intolrance due to fatigue
Risk for muscle atrophy
Integumentary system :
 Risk for impaired skin integrity.
High risk for injury.
 High risk for infection.
Self care deficit
Psychological nursing diagnosis :
Risk for Self-esteem disturbance.
Risk for ineffective role performance.
Risk for impaired social interaction.
Risk for ineffective individual coping.
Risk for ineffective family coping.
Risk for sleep pattern disturbance.
Risk for altered thought processes.
Risk for knowledge deficit.
Risk for powerlessness.
Risk for hopelessness
Planning:
During planning the nurse synthesizes information
from resources such as knowledge of the role of
respiratory and physical therapy, standards such as
skin care guidelines from the Agency for Health
Care Policy and Research (AHCPR), protocols for
clients at risk for falls, attitudes such as creativity
and perseverance, and past experiences with
dependent patients.
Implementation:
Nursing interventions related to highly dependent
patient are classified into:
Health promotion activities.
Acute care-based implementations.
Health promotion:
Health promotion activities include
a variety of interventions that can be
divided into education, prevention and early
detection. In this section exercise are
emphasized.
Exercise:
The purpose of exercise:
-To restore, maintain, or increase the strength of
muscles.
-To maintain, increase the flexibility of joint.
-To maintain or promote the growth of bones.
-To improve function of body systems
Types of exercise:
 Passive: These exercises are carried out by the nurse,
without assistance form the patient. Passive exercises
will not preserve muscle mass or bone mineralization
because there is no voluntary contraction, lengthening
of muscle, or tension on bones.
Active assistive: These exercises are performed by
the patient with assistance from the nurse. Active
assistive exercises encourage normal muscle function
while the nurse supports the distal joint.
Active: Active exercises are performed by the
patient, without assistance, to increase muscle
strength.
Resistive: These are active exercises performed by
the patient by pulling or pushing against an
opposing force.
Comparison between effect of exercise and effect of
immobility on body system
Body system
Effect of immobility Effect of exercise
Cardiovascular
system
•Increase cardiac
• Increase efficiency
workload
•Increase risk for
orthostatic
hypotension
•Increase risk for
venous thrombosis
of heart
• Decrease resting
heart rate& blood
pressure
• Increase blood
flow& oxygenation of
all body parts
Body system Effect of
immobility
Effect of
exercise
Respiratory
system
•Decrease depth of
•Increase depth of
respiration
•Decrease rate of
respiration
•Pooling of
secretion (stasis)
•Impaired gas
exchange
respiration
•Increase
respiratory rate
•Increase gas
exchange in alveolar
•Increase rate of
CO2 excretion
Body
system
Effect of immobility Effect of
exercise
GIT
system
•Decrease appetite
•Increase appetite
•Altered protein metabolism
•Increase intestinal
•Altered digestion &
tone
utilization of nutrients
•Difficulty in passing stools
(constipation)
•Diarrhea may result from a
fecal impaction
(accumulation of hardened
feces)
Body system
Effect of
immobility
Effect of
exercise
Musculoskeletal
system
•Decreased muscle
•Increase muscle
tone & strength
•Decreased joint
mobility &
flexibility
•Increase risk for
contracture
formation
efficiency
•Increase
coordination
•Increase efficiency
of nerve impulse
transmission
Actual patient care:
Metabolic system:
 The dependent immobilized patient requires a highprotein, high-calorie diet with vitamin B and C
supplements.
 Protein is needed to repair injured tissue and rebuild
depleted protein stores.
 A high-calorie intake provides sufficient fuel to meet
metabolic needs and to replace subcutaneous tissue.
 Supplementation with vitamin C is necessary to replace
protein stores.
 Vitamin B complex is needed for skin integrity and
wound healing.
If the client is unable to eat, nutrition must be
provided parenterally or enterally.
Enteral feedings include delivery through a
nasogastric, gastrostomy, or jejunostomy tube of
high-protein, high-calorie solutions with complete
requirements of vitamins, minerals, and
electrolytes.
•Total parenteral nutrition refers to delivery of
nutritional supplements through a central or
peripheral intravenous catheter.
Respiratory system:
Nursing interventions for the respiratory
system are aimed at:
Promoting expansion of the chest and lung.
Preventing stasis of pulmonary secretion.
Maintaining a patent airway.
Promoting adequate exchange of respiratory gases.
Promoting expansion of the chest and lungs:
The nurse promotes chest expansion with several
interventions:
 Changing the position of the client at least every 2
hours allows the dependent lung regions to
reexpand.
Reexpansion maintains the elastic recoil property of the
lungs and clears the dependent lung regions of pulmonary
secretions.
The nurse should encourage the client to deep breathe
and cough every 1 to 2 hours.
Alert clients can be taught to deep breathe or yawn every
hour or to use an incentive spirometer.
These respiratory interventions will aid alveolar
expansion and prevent atelectasis.
Coughing reduces the stasis of pulmonary secretions.
For unconscious clients with an artificial airway, the
nurse can expand the chest and lungs by using an ambubag.
Preventing stasis of pulmonary secretions:
Stagnant secretions accumulating in the bronchi and
lungs may lead to growth of bacteria and subsequent
development of pneumonia.
Stagnation of secretions can be reduced by changing
the client’s position every 2 hours.
The immobile client should take in minimum of
2000 ml of fluid a day, if not contraindicated, to help
keep mucociliary clearance normal.
In clients free from infection and with adequate
hydration, pulmonary secretions will appear thin,
watery, and clear.
The client can easily remove the secretions with
coughing.
Without adequate hydration the secretions are thick and
tenacious and difficult to remove.
Encouraging fluids also benefits in helping with bowel
and urine elimination and aids in maintaining circulation
and skin integrity.
Chest physiotherapy (CPT):
(percussion and positioning) is an effective method for
preventing pulmonary secretion stasis.
CPT techniques help the client to drain secretions from
specific segments of the bronchi and lungs into the
trachea so that the client can cough and expel the
secretions.
Maintaining a patent airway:
Highly dependent patient and those on bed restore
generally weakened. If weakness progresses, the cough
reflex gradually becomes inefficient.
The stasis of secretions in the lungs may be life
threatening for an immobilized client because
hypostatic pneumonia can easily develop.
Dislodging and mobilizing the stagnant secretions
reduce the risk of pneumonia.
The nurse should actively work with the client to
deep breathe and cough every 1 to 2 hours.
In the highly dependent patient an obstructed
airway is usually a result of mucous plug. The nurse
can implement several therapies, such as CPT, to
reduce the risk of mucous plugs and to maintain a
patent airway.
Nasotracheal or orotracheal suction techniques
may be sued to remove secretions in the upper
airways of a client who is unable to cough
productively.
Cardiovascular system:
The effects of bed rest or highly dependent
patients on the cardiovascular system
include:
Orthostatic hypotension.
Increased cardiac workload.
Thrombus formation.
N.B. Nursing therapies are designed to minimize
or prevent these alterations.
Reducing orthostatic hypotension:
The nurse attempts to get the client moving as soon
as the physical condition allows, even if this only
involves dangling at the bedside or moving to a chair.
 Reducing cardiac workload:
A primary intervention is to discourage the client
from using the valsalva maneuver. When using this
maneuver, the client holds his or her breath, which
increases intrathoracic pressure. This decreases
venous return and cardiac output.
When the strain is released, venous return and cardiac
output immediately increase and systolic blood
pressure and pulse pressure rise.
Preventing thrombus formation:
Many interventions reduce the risk of thrombus
formation in the immobilized client.
Leg exercises, encouraging fluids, position changes,
and teaching should begin when the client becomes
immobile.
Musculoskeletal system:
The highly dependent client must receive some
exercise to prevent muscle atrophy and joint
contractures.
If the client is unable to move part or all of the body,
the nurse must perform passive ROM exercises for all
immobilized joints while bathing the client and at
least 2 or 3 more times a day.
Elastic stockings also aid in maintaining external
pressure on the muscles of the lower extremities and
thus may promote venous return.
ROM exercises are designed to reduce the risk of
contractures but may also aid in preventing thrombi.
Integumentary system:
The major risk to the skin from restricted
mobility is the formation of pressure ulcers.
Interventions aimed at prevention are positioning,
skin care, and the use of therapeutic devices to relieve
pressure.
 The immobilized client’s position should be
changed according to the client’s activity level,
perceptual ability, treatment protocols, and daily
routine.
Although turning every 1 to 2 hours is recommended
for preventing ulcers, it may also be necessary to use
devices for reliving pressure.
Elimination system:
The nursing interventions for maintaining
optimal urinary functioning are directed at keeping
the client well hydrated and preventing urinary stasis,
calculi, and infections without causing bladder
distention.
Adequate hydration (e.g., 2000 to 3000 ml of fluids
per day) helps prevent renal calculi and urinary tract
infections.
If the client is incontinent, the nurse should
modify the care plan to include toileting aids and a
hygiene schedule so that the increased urinary
output does not cause skin breakdown.
To prevent bladder distention, the nurse assesses
the frequency and amount of urinary output.
The nurse must also record the frequency and
consistency of bowel movements.
A diet rich in fluids, fruits, vegetables, and fiber
can facilitate normal peristalsis.
If a client is unable to maintain regular bowel
patterns, the physician may order stool softeners,
cathartics, or enemas.
Psychosocial changes:
Responsibilities of the nurse in meeting the
psychosocial needs of highly dependent patients
Preventing the serious physiological consequences
that prohibit the patient from regaining some degree
of independence.
Relating to the patient as a whole person so that she
sees herself as a person of dignity and worth.
Providing diversionary activity to help decrease
boredom.
Nurses must work with patients to explore strengths
so that the patient may maintain their self esteem.
Evaluation:
To evaluate outcomes and response to nursing care,
the nurse measures the effectiveness of all
interventions.
The outcomes are compared with the selected
outcomes, such as the client’s ability to maintain or
improve body alignment, joint mobility, walking,
moving, or transferring, or to prevent the hazards of
immobility or highly restricted of activities .
 The nurse evaluates specific interventions designed
to promote body alignment, improve mobility, and
protect the client from the hazards of immobility.