Transcript Impact of Hospitalization, Aging and Negligencex

Impact of Hospitalization
Chapter 1
C. Cummings,
RN, EdD
What is Health?
• How do you define health?
• Health-illness continuum
• Is it the ability of one to function in society?
• Is it disease free?
• Health: free from disease/illness. Different for everyone.
• Needs to be their goal for health, not ours.
WHO’s definition of health
• State of complete physical, mental and social
well-being
• Is this realistic?
• Holistic health- body, mind and spirit as part
of a person’s level of wellness
• (not really realistic)
Body-Mind-Spirit connection
Quality of Life
• Quality of Life, refers to 2 concepts:
– Subjectivity: perceptions of satisfaction with their
functional level
– Multidimensionality: physical, functional,
emotional and social well-being
Health Promotion and Protection
• Health Promotion: What is this?
• Healthy people 2010: U.S. DHHS
– 2 National Goals:
• Increase quality and years of healthy life
• Eliminate health disparities among demographic groups
• Pender (1987) describes health promotion as a
positive activity that protects someone against
illness
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DRG: diagnosis related group. If you are admitted to hospital… hospital can get a certain amt of
money from Medicare for that diagnosis. Hospital has to get every thing that patient needs w/in
that amount of money. Now, the patient will add more diagnosis so the patient is able to get more
money.
Pender (nurse) has written a lot on health promotion
Activities to Promote Health
• Name some activities to promote health
• Why are the effective and why might they not
be?
• (exercise, smoking, diet, seat belt, stress relief
activities, lower cholesterol, diabetes
prevention)
Healthy People 2010
• http://www.healthypeople.gov/
• Look at leading health indicators. Gov says we have to go by these things!
• Physical activity, overweight & obesity, tobacco use, substance abuse, resp
sex behavior, mental health, injury & violence, environmental quality,
immunization and access to health care.
Healthy People 2010
• What are the 6 target areas of health
promotion?
• Do you think there is a difference between
racial and ethnic groups?
• Yes, there is a difference w/ access to care, cultural differences w/ tobacco
…
use or diet, communication issues
Reasons for Differences
• Poor Socioeconomic
status
• Health beliefs and
behaviors
• Access to health care
• Environmental factors
• Direct and indirect
manifestations of
discrimination
• Lack of health insurance
• Insufficient
transportation
• Geographic location
• Cost of services
• Language barriers
• (transportation difficult
here in Jax for elders)
Nursing’s Role
• What can nurses do to decrease these
differences?
• What is transcultural nursing?
– Area of study that focuses on the care, health and
illness patterns as related to one’s cultural beliefs,
values and practices
• What is cultural competence?
• Name some areas that may have differences for a
hospitalized patient.
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Being familiar w/ other cultures & groups… being aware, not putting our own prejudices
& bias on them.
Getting patient to understand meds
Illness Prevention
• People must be motivated to prevent an
illness from occurring
• What do you think motivates them?
• What role can you as a nurse play?
• The pt has to see it as a problem. Families may motivvate… hopefully as a
nurse we motivate.
Three Types of Prevention
• Primary Prevention:
– Early, health maintenance activities
• Secondary Prevention:
– Early detection and treatment of a disease or
condition (when the person has the disease)
• Tertiary prevention:
– Rehabilitation once the disease is stabilized
– Return to their highest level of functioning
What types of Prevention are these?
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Cardiac Rehab Program
Colonoscopy after 50
Hepatitis B vaccine
Cholesterol testing
Asthma camp for
children
• Running with a group
• Secondary is hardest to
pick out…
• Tertiary
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Primary or secondary
Primary
Secondary
Tertiary
• Primary
Impact of Hospitalization
• What impact do you think being hospitalized
has on someone?
• List three nursing diagnoses related to
hospitalization.
• Communicate w/ patients about what is going on.
• Allow patient to make choices about their care. Powerlessness is a huge
problem.
Powerlessness
• Ackley’s definition of powerlessness:
– Perception that one’s own action will not
significantly affect an outcome
– Lack of control over the situation
• How does being hospitalized contribute to this
diagnosis?
• (if you tell most patients why youar edoing
something, they will cooperate)
Powerlessness
• List some patient behaviors that may
demonstrate this diagnosis
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May be angry… may take the anger out on the nurse… may withdraw or be
depressed…
• NOC outcomes may be the following:
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Health beliefs: Perceived control
Health beliefs: Perceived ability to preform
Participation in health care decisions
Depression level: self-control
Nursing Interventions
• List 5 things that nurses can do to help the
patient experiencing powerlessness
• How can you empower a patient?
Hopelessness
• Subjective state in which the person sees
limited or no alternatives and is unable to
mobilize any energy to correct
• What do you see as the difference between
hopelessness and powerlessness?
• What patient behaviors may be different?
• Get a family member in w/ them… Difference: powerlessness; you feel like
you can get the control back. Hopelessness: watch for depression &
suicidal behavior
Hopelessness
• List 4 nursing interventions that may be
helpful.
• What should the nurse be aware of, if the
patient is exhibiting hopelessness?
• Talk to them, keep them involved, talk about experiences… long term, be
honest but tell that we will do everything we can
Role of the Nurse
• What then is the role of the nurse in patient
care?
– Coordinator of Care
– Caregiver
– Continuing Care Planner: discharge
– Educator
– Advocate
– Change Agent
Theories of Chronic Illness
• Chronic Illness
– Condition or illness that has existed for more than 3
months
• Chronic Disease accounts for 70% of all health
care deaths and 60% of all health care costs
– $510 billion in 2000 and may increase $2 trillion by
2020
– Over 125 million people have one or more chronic
disease
• Heart disease & cancer, numbers 1 & 2
• Chronic disease= more than 3 months
Shifting Perspective Model
Uncertainty Model
first diagnosed: uncertain. Get more understanding over time
Model of Uncertainty in Illness
How to adapt & cope.
Inference Illusion (get info from web md & make an inference about what I think the heart
disease is)
Chronic Illnesses
• List the top 5 common chronic illnesses
– 1.
– 2.
– 3.
– 4.
– 5.
• What is the leading cause of death for those
over 65?
Chronic Illnesses
• http://www.cdc.gov/nchs/FASTATS/default.htm
• http://www.ncsl.org/programs/health/phchronic.
htm
• CDC: leading cause of death: heart disease is number 1, cancer #2,
stroke, chronic lower resp disease, accidents, diabetes, alzheimer’s
disease, influenza & penumonia, renal syndromes, septicemia
• Life expectancy: 77.7 years
• death rate 940 per 100,000
• NCLS website: state information, website not up right now
Theories of Chronic Illness
• Why are some patients more independent
than others?
– Some illnesses are less debilitating
– Some are controlled by medications
– Some have the resources to self-manage
• Financial
• Emotional
Theories of Chronic Illness
• Shifting Perspectives
– Shift between well and ill
– Taking on the Sick Role
– Finding meaning, hope and quality of life
– Accepting or denying illness
Issues with the Chronically Ill
• Education of RN’s about elderly and chronic
illness
– Only 12% of RN’s are from ethically diverse
groups, while 33% of ill are from these groups
• Financial issues
– Medications, MD visits, home care and ADL’s
• Cultural values
– Not a priority for family support
– Need more nurses from other cultures
Health Care Needs of the Aging
Irma B. Ancheta, Ph. D, RN
Peggy McCartt, RN, PhD (c), CCRN, ARNP
Learning Objectives
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Identify the four subgroups of older adults
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Discuss common health issues that may concern the older adult
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Explain why older adults are at risk for falls
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Discuss polypharmacy in the older adult
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Discuss economic issues for older adults
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Describe government and community resources for older adults
Four Subgroups of Older Adults
• 65-74 years of age: young
old
• 75-84 years of age:
middle old
• 85-99 years of age:
old old
• 100 years of age or more:
the elite old
Questions About These Groups
• Which is the fastest growing of the four
subgroups?
• What percentage of older adults are living in
the community either at home, in assistedliving, or in community retirement complexes?
• Old old is the fastest growing
• Almost 80% are living in the community.
• Page 15 in the book
Health Issues for Older Adults
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Health Promotion
Self-management
Nutritional Awareness
Physical Fitness and Mobility
Stress Management
Accidents
Drug Use and Misuse
Mental Health/Behavioral
Health Problems
• Elder Neglect and Abuse
• (isolation, accidents, falls,
leaving stove on, etc…)
Relocation Stress Syndrome
• “physiological and /or psychological distress
following transfer from one environment to
another.”
(NANDA, 2003)
(transferring from one environment to another
is very stressful for elderly… confusing)
Health Promotion
Negative Risk Factors for
Healthy Aging
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Alcohol Abuse
Smoking
Depression
Lack of Exercise
Obesity
Health Promotion
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Yearly Influenza Vaccinations
Pneumococcal Vaccination
Tetanus Immunization
Create Hazard Free Environment
Wear Seat Belts
Install Smoke Detectors
Be Cautious About Medication
Use
• Take One Aspirin a Day
• Moderate Alcohol Intake
• No Smoking
Self-management
Find Opportunities
to be productive
Maintain as much control
as possible over their
lives
Participate in decision
making
Perform as many tasks as
possible (avoid being an
enabler)
Nutritional Awareness
• Increase Intake of Fiber
and Complex
Carbohydrates
(add Benefiber in coffee)
• Decrease Intake of Dietary
Fat
• Increase Calcium Intake
(also need sunlight
exposure)
Nutritional Awareness
Causes of poor nutrition (not eating/ eating less
or overeating) in the elderly:
[1] Loneliness (PF)
[2] Depression (SB)
[3] Boredom
………………..lose the will to live……
Physical Fitness and Mobility
Exercise Regularly (three
to five times a week for
30 minutes per session)
Some Weight Bearing
Exercises (increase
strength)
Improve regularity of
bowel movement
Physical Fitness and Mobility
• Use of walker, cane, wheelchair, motorized
scooter
• Health and beauty trips
Stress Management
• Older Adults Cope with
Stress as they Did when
they were Younger
• Awareness of Physical
and Economic
Constraints
• (get stressed that
they can’t do what
they used to be able
to do…. Frustration)
Accidents
• Most Accidents are at
Home
FALLS
Drug Use and Misuse
• POLYPHARMACY
• (occurs often due to
elderly pt receiving a
lot of different meds
from different
pharmacies)
Drug Use and Misuse
Older people have less muscle mass…..
…….inclined to get easily toxic to drugs…
…….beware of how drugs affect the elderly
Has more to do with liver involvement, bioavailability. Liver just not as
effective. Can also be a renal problem w/ excretion. Statins are
really rough on the liver (cholesterol lowering drugs). Tylenol is also
rough on the liver.
Mental Health/Behavioral Health Problems
• Legally Competent
• Clinically Competent
• Depression
(…the need to be intellectually
stimulated)
• Dementia/Delirium
Depression
Watch out for:
[1] early morning insomnia
[2] excessive daytime sleeping
[3] poor appetite
[4] unwillingness to participate in social and
recreational activities
Wake up at 3 am, don’t sleep well, sleep throughout the day but not good at
night. Depression very common in the elderly.
Depression: Treatment
[1] Drug therapy
[2] Psychotherapy
[3] Awareness of depression and eliminate
possible causes.
Dementia (OBS) vs. Delirium
Chronic
Progressive
Example:
Alzheimer’s disease
• Organic brain syndrome =
dementia
• Delirium = acute & reversible
• Pain meds can also cause
delirium as well as sleep aids like
restoril or ambien. UTIs or sepsis
also cause confusion.
• Acute
• Reversible
2 types:
[1] Hyperactive
[2] Hypoactive
Cultural Sensitivity/ Considerations
[1] Food
[2] Attitudes
[3] Perceptions
[4] TFC Channel
Elder Neglect and Abuse
• Neglect
(failure to provide basic
needs)
• Physical Abuse
(burns)
• Financial Abuse
(mismanaged property)
• Emotional Abuse
• (threats, humiliation)
Government and Community Resources
Income
[1] SSI/SSDI
Health Insurance
[1] Medicare
[2] Medical/Medicaid
Housing Programs
Social Services
Research Agencies
Churches
Meals on Wheels
• Medicaid is state
funded
• Medicare is federally
funded
The Future of Gerontology Nursing
• Nurses will practice taking
care of older adults in acute
care, long term care and
community-based settings
• Gerontological Certification
• Gerontology ARNP
Legal & Ethical Issues in
Adult Health Nursing
M. Catherine Hough, PhD, RN, Associate Professor
University of North Florida
School of Nursing
Define AUTONOMY?
INFORMED CONSENT
• Need informed consent for
anything invasive.
• Nurses don’t sign this… the
physician signs the form. In last
10 years, the physician has to sign
the form.
• We can witness that the patient is
the one that signed, but we give
information about the procedure.
• Only time you can bypass a blood
consent is an emergency.
Otherwise you have to give
consent.
• Basic nursing procedures don’t
need informend consent.
Elements
• CAPACITY The individual must posses:
1. the capacity/ability to understand their situation
2. the capacity/ability to state what their values are
3. the capacity/ability to tie a & b together
(relate their values to their specific situation)
• VOLUNTARY Must be made freely without coercion
• DISCLOSURE Adequate information to enable the individual to consent or
refuse medical treatment
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Married, pregnant you are considered an adult & don’t need parent’s
consent.
These are the 3 elements of informed consent.
Possible Standards
• Subjective Standard
refers to all information that the person could possibly want or
need to know to be able to make a decision
• Reasonable Person Standard
all that a reasonable person would need to know to be able to
made a decision
• Professional Practice Standard
only provide that information that other physicians provide in
similar situations
Sometimes you (as a nurse) are not allowed to give ALL the information.
We can’t say what the x ray showed… the physician needs to tell them
that information.
Varieties of Consent
• Tacit consent- expressed passively by omission
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ex: if the residents of a
nursing home voice no objection to a change in dinner time, there is tacit
consent
Implicit/Implied consent- inferred from action ex: a medical
procedure may be implicit in consent to another procedure
Presumed consent - what we know of the person or general theory of
rational will
– ex: patient in ER unable to state wishes at present
• Implicit/Implied: agree to take care of me,
whatever it takes
• Presumed consent: you think you know what they
want to have done
FORMS OF NEGLIGENCE
• Malfeasance - Unlawful or improper act (take $ from a pt)
• Misfeasance - Improper performance of an act (do something
wrong… don’t know how to use the equiptment & do it wrong…
do CPR wrong)
• Nonfeasance - Failure to act when there is a duty to act as a
reasonable person would
• Malpractice - negligence of a professional person
• Criminal negligence - reckless, willful disregard for the safety of
another
DEGREES OF NEGLIGENCE
• Ordinary Negligence
Failure to do what a reasonably prudent person would do under the same
or similar circumstances
• Gross Negligence
Intentional failure to perform a duty in reckless disregard
of the consequences
With nursing we are held to standards.. Ordinary negligence… not
checking name bands Gross negligence: coming to work drunk or
impaired.
Tort Liability for
Medical Malpractice
TWO PURPOSES:
(why people sue)
• Compensation
• Deterrence
ELEMENTS OF A NEGLIGENCE CLAIM
• Duty
Existence of a legal obligation to provide
care
• 4 major elements:
• Duty to the patient. I am the person taking care of the person. If a
nurse makes a mistake, the doctor is held responsible for that
mistake because she is working under the doctor. They can sue
the nurse & the charge nurse.
ELEMENTS OF A NEGLIGENCE CLAIM
• Breach of duty: as a new nurse, if I can’t handle what is
going on, I need to tell the person in charge. Talk to the
hospital where you are.
• Breach
Failure to do what a reasonable professional would
do under similar circumstances
ELEMENTS OF A NEGLIGENCE CLAIM
• Damages
Physical, economic or psychological
injury
What I did to the patient… did it cause damages. Fall asleep while on duty
but there was no injury, can’t really sue for malpractice.
ELEMENTS OF A NEGLIGENCE CLAIM
• Causation
Relationship between the breach and
resulting injury or loss
• Did my action cause damage (death or injury) or
would that death have happened anyways.
• Hospice nurse gives too much morphine & the patient
dies… that patient would have died anyways.
ELEMENTS OF A NEGLIGENCE CLAIM
• DUTY
• BREACH
• DAMAGES
• CAUSATION
Nursing Documentation
Nursing DOCUMENTATION
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Part of a legal record
Must be factual and objective
No spelling errors
Must be neat
Must correct errors in documentation according to
institution policies
• NEVER USE WHITE OUT!!!!!
• (must be factual… nothing subjective)
Error with Documentation
(actual notes unedited)
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Patient has chest pain if she lies on her left
side for over a year
on the 2nd day the knee was better and on
the 3rd day it disappeared completely
the patient has been depressed ever since
she began seeing me in 1993
the patient is tearful and crying constantly.
She also appears to be depressed
Error with Documentation
(actual notes unedited) ...
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Discharged status: Alive but without
permission
Healthy appearing decrepit 69 year old male,
mentally alert but forgetful
The patient refused an autopsy
Patient had waffles for breakfast and anorexia
for lunch
She is numb from her toes down
The skin was moist and dry
Error with Documentation
(actual notes unedited)
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She stated that she had been constipated for
most of her life, until she got a divorce
Patient has two teenage children but no other
abnormalities
Skin: somewhat pale but present
Quite thin with multiple areas of skin on the
hips & sacrum
Occasional, constant, infrequent headaches
Patient was alert and unresponsive
And the best
“Large brown stool
ambulating in the
hall”