Caring for Elderly Patients: An Overview
Based on the book Brunner and Suddarth’s Textbook of Medical Surgical Nursing, it can be seen that caring for the elderly comes with an assortment of complications that need to be taken into consideration prior to implementing any form of care plan. Busby-Whitehead (2012) backs up this assertion by explaining that some of the complications that arise from caring for the elderly come in the form of the accumulation of prior existing conditions that are exacerbated by their advanced age (Busby-Whitehead, 2012). Some examples that Koopmans (2013) points out come in the form of patients that develop arthritis, multiple sclerosis, Parkinson’s, liver damage and other such conditions. It is due to this accumulation of conditions that multiple types of medication are often prescribed in order to address them individually, however, Koopmans (2013) points out that as compared to younger patients the potential for toxicity build-up (i.e. the accumulation of different chemicals within the body as medicine is not efficiently flushed out) is far higher in the elderly due to their advanced age which results in a less efficient excretory system.
As such, nurses need to take this into consideration when applying dosages since what may work for a younger patient will most likely kill an older one. The same methodology applies when elderly patients develop infections due to a wide variety of potential causes. While antibiotics are an effective treatment for various infections, the fact remains that their use in the elderly should be approached with caution. Koopmans (2013) explains in a case example that an elderly patient that was admitted to a hospital due to work induced exhaustion and, as a result, developed a bacterial infection due to a compromised immune system (Koopmans, 2013). An 800 mg dose of Telithromycin was administered due to the presence of acute bacterial sinusitis and was given for 5 days over the course of the treatment procedure. Unfortunately, an adverse reaction occurred in the patient by the third day of treatment resulting in the need for resuscitation which failed. Autopsy reports indicated that the patient experienced a form of shock due to a combination of pre-existing heath conditions, their compromised immune system as well as the dosage given. Despite the fact that the administered dosage was considered as “standard” the fact remained that when it was administered by the nurse on duty they neglected to take into consideration the accumulation of pre-existing conditions and the current state of the patient which led to them assuming that a standard dose would have been fine.
This example shows that it is erroneous to believe that medicine is a “one size fits all” practice wherein what applies to a young patient with no prior existing conditions would be applicable to an elderly patient with a weak body. Caring for the elderly comes with the necessity of examining how their age factors into the treatment procedure as well as how modifications may be necessary to standard procedures in order to ensure proper care is administered. When creating any plan related to caring for the elderly, what must also be taken into consideration are possible health requirements that go beyond a standard hospital visit. Various individuals when they grow older develop various forms of disabilities and bodily deteriorations that entail certain medical requirements or observation in order to ensure that they don’t get worse Busby-Whitehead (2012).
In certain cases involving highly sensitive elderly individuals, it becomes an almost daily necessity to ensure that they are doing well or rush them immediately to a proper care facility when complications occur. It is due to this that additional outpatient procedures may be needed on the part of the nursing staff at a hospital. This may involve developing a care plan for the elderly patient that will be carried out by their children as well as doing weekly or monthly calls to check up on the status of the patient to make sure that their current condition is either improving or deteriorating. Guidelines from the American Geriatrics Society Expert Panel on the Care of Older Adults suggests that clinicians should elicit and incorporate patient preferences into medical decision-making for older adults with multi-morbidity. This needs to be considered in relation to creating a care plan since this makes elderly individuals feel that they are in charge of their treatment and helps to empower them into making significant choices about their care. Therefore, this would entail providing patients with information that they can understand and listening to their views as well as those of their children.
Creating a care plan for the elderly patient also ensures that once they leave the hospital, they can be properly cared for by their kids which should help in addressing their health concerns and prolong their life. Lastly, older patients are prone to injuries associated to falls. These patients should be offered multi-factorial risk assessments and interventions performed by skilled healthcare professionals. The risk assessment should include the identification of the history of falls and evaluation of balance, mobility, osteoporosis risk, functional ability, visual and cognitive impairment, urinary inconsistency and home hazards. By implementing these factors, this helps to reduce repeated instances of injury resulting in a far better state of being for the patient. Overall, it can be stated that caring for elderly patients often poses significant challenges to care providers. Even though this group is composed of diverse patients with different characteristics, they share some age related features that expose them geriatric syndromes and diseases. Nurses caring for this population must recognize the importance of carrying out ongoing, thorough, functional, psychosocial and physical assessments and identify evidence-based interventions intended to advance care.
Physical, Heritage and Labs Assessment of Patient
Clinical Assessment
Mrs. Nina Myers, a 76-year-old woman was admitted to the nursing unit from the emergency department. She had a distressing pain on the left side of the chest for 3 days. She has a medical history significant for hypertension, dyslipidemia, diabetes, gout, fibromyalgia and lumbar spinal stenosis with radiculopathy.
She was first presented to the nursing unit with left sided chest pains on 11/23/13. Admission physical examinations revealed negative serial tropoins and the CT chest tested negative for pulmonary embolism and myocardial perfusion stress test. Her CT chest showed mild perinroncial thickening and she tested positive for leukocytois with a WBC of 16.4. Her admission U/A tested positive for nitrites and leukocytes esterase and culture consistent of Ecoli urinary tract infection. She also had bacteremia with both blood cultures positive for gram-positive cocci identified as coagulase negative Staph. When her condition optimized, she was discharged to Victory lakes for rehabilitation with the plan to continue Vancomycin for 10 more days and Oral Keflex for 5 more days.
Heritage Assessment
An examination of her ethnic heritage as well as her family genealogy revealed no significant traits that would indicate that she is at risk for any heart related diseases, however, a preliminary examination of the work of Folkins & Longacre (2013) which examined the development of medical conditions in various parts of the world did indicate that individuals with Italian ancestry did possess a predilection towards weight gain in the latter part of their lives. While not as significant as those of Samoan ancestry, there was is still a significant degree of weight gain which often results in the build of fat deposits in and around the arterial valve of the heart which is often coupled by plaque build-up within that individual’s arteries (Folkins & Longacre, 2013). When examining the patient at the present, it is surprising to see that a 76 year old woman actually weighed 188 pounds and, as per the medical history, it was revealed that she had actually gained 5 pounds recently. Taking this into consideration and the correlation between the sudden acute pain experienced by the patient in the left side of her heart as well as the fact that she experienced difficulty breathing while gardening, it can be assumed that her issues are weight related especially when taking into consideration the work of Folkins & Longacre (2013) which stated that such a condition was actually common among individuals of Italian ancestry that did not have healthy diets or performed regular physical exercise.
Labs Assessment # 2
After 2 weeks, her CXR showed moderate sized pleural effusion with retro cardiac airspace opacity suspicious for possible pneumonia, stable cardiomegaly, and mild right basilar atelectasis. She was treated for pneumonia, bronchitis, COPD, and possible acute diastolic heart failure. She was started on IV Levaquin, Cefepine later, and doxycycline. However, even despite of taking the antibiotics her respiratory system has not been improving. The patient was treated with IV solumedrol and continued with prednisone. She was also continued on scheduled nebulizers Her cardiology was also checked for questionable diastolic heart failure. Her echo was normal but recorded as limited for the study. Diuretics were recommended and the cardiology signed off her case.
Physical Assessment
Based on the data provided in the examination and the fact that the testing from the labs found no acute condition that would explain her heart condition, it is the assessment of this report that the patient’s condition was brought about through Obesity hypoventilation syndrome (OHS). Justification behind this assessment is based on the activity done by the patient prior to being admitted to the hospital, namely gardening. While obesity is often associated with individuals that weigh 250 pounds or more beyond the weight allotment for their height, it can actually be applied to a multitude of individuals that exceed their allotted weight for their height. As seen in the case of Mrs. Nina Myers, she weighed 188 pounds and was shown to be gaining weight. Combined with her case of gout, hypertension and her shortness of breath after a moderate level of activity, this is indicative of her weight gain combined with her age affecting her capacity to breath properly and could be considered as a contributing factor towards the pain she felt in her heart.
Other contributing factors towards this assessment was that her echocardiogram was rather poor and was not able to show a clear enough picture for an accurate diagnosis. Further evidence behind this assessment can be seen in the work of Weltman (2014) which examined the physical issues that arise from overweight individuals exerting themselves. Weltman (2014) explained that individuals that in instances where overweight individuals were bending over (i.e. placing their head closer to their chest) which the patient had done while gardening, their capacity to breathe is restricted as a direct result of the excess weight pressing down on their lungs. Further exertion under this low oxygen state has been noted to cause heart pain and sudden difficulty in breathing which could result in further complications (Weltman, 2014). Taking these symptoms into consideration and the fact that her prior conditions point towards issues related to her weight (i.e. the hypertension, gout, etc.), the physical assessment of this report points towards the patient having heart and breathing complications due to her weight and, as such, an outpatient care guide for the children of Mrs. Nina Myers to administer to her is needed.
Pathophysiology
Weight gain in patient – as explained in the diagnosis, the patient was noted as having Type 2 diabetes which various medical studies have shown is a precursor towards weight gain in some patients.
Hypertension – the resulting hypertension of the patient can be the result of either old age or her subsequent weight which may facilitate such a condition as well.
Description of current patient order for Diet, Activity, Therapy and Rationale
Based on the assessment that was conducted, it is the recommendation of this study that the patient lessen her intake of simple carbohydrates and instead focus on eating more complex carbohydrates that are rich in fibre. Other additional recommendations come in the form of including a 15 minute light to moderate exercise regimen per day that includes walking around that person’s neighbourhood with someone to accompany and monitor her. The basis behind this recommendation stems from the earlier assessment that the main issue with the patient is the fact that their weight is contributing towards their current condition. As a result, this places a burden on their heart which will only get worse as time goes on. It is based on this that a shift towards taking out simple carbohydrates (i.e. sugars, white bread, etc.) and replacing it with complex carbohydrates in the form of beans, lentils and vegetables should help in reducing the patient’s weight to a level that is more acceptable and would strain their heart a lot less. In order to better facilitate the process, a light to moderate exercise regimen would be ideal since this would enable the patient to burn more calories throughout the day and thus facilitate greater fat loss. Do note that the exercise should only consist of slowly walking, either outside or on a treadmill, since the advanced years of the patient may not positive react to strenuous exercise given their current condition. Another factor that should be taken into consideration is the fact that the patient is currently living alone which may result in a relapse of bad habits.
In his examination of long term care for the elderly Nay (1998) points out that assisted living services in the form of care givers is actually a growing industry within the U.S. and is actually well established in countries such as Japan and Europe due to their current aging populations (Nay, 1998). Such services present an alternative to individuals who are either too busy or unwilling to directly care for their aging parents. When creating any plan for future care and support what must be taken into consideration is up to what point are a person’s parents able to take care themselves until it comes to a point where they are in effective unable to proper do daily tasks due to physical deterioration (Nay, 1998). In such cases either a nursing home or a daily caregiver services should be incorporated into any future plans if a person is either unwilling or incapable of assisting their elderly parents on a daily basis. It is the recommendation of this report that the patient be placed in an assisted living facility since they will be able to better monitor her health and give her the necessary supervision to ensure that she gets to exercise adequately. It is in the opinion of this report that should the following diet and exercise plan be followed, the patient’s overall condition should improve drastically over the next few months.
Plan of Care using NANDA
Based on an examination of the physical assessment and lab results of the patient, the following NANDA nursing diagnoses have been selected for use in addressing the current problem of the patient:
- Risk-prone health behaviour
- Ineffective self-health management
- Imbalanced nutrition: more than body requirements
To address the issue the following health plan has been created to create a measurable and time referenced method of examining the patient and determining their progression towards better health:
NOC outcomes
- 0300 self care: activities of daily living (ADL)
- 0400 cardiac pump effectiveness
- 1302 coping
- 2301 medication response
- 0306 self care: instrumental activities of daily living (IADL)
- 1609 treatment behaviour: illness or injury
- 1824 knowledge: illness care
Measured outcomes in this case come in the form of the patient’s psychological and biological response to the treatment and how this creates better health outcomes.
Current Medication
Acetaminophen is basically prescribed in order to deal with minor pain and can be metabolized by the liver. Since the presence of drugs that promote the production of liver enzymes that reduces the effectiveness of Acetaminophen are not present, such as isoniazid, rifampin, there are no perceived issues in its usage. Since the patient has no reported allergies and Duonebs do not react adversely with Acetaminophen, there are no perceived issues in using this drug to treat heart blockage issues. Allopurinol is a drug commonly used to treat gout and to reduce the amount of uric acid in the blood. Overall, when examining the drugs used by the patient there are apparently no complications in their combination of use or in their combination with the needed diet.
Teaching Plan
Davis (1993) in his article, “Caring for the Elderly”, brings up 4 specific points that he states need to be addressed when taking care of the elderly, namely: the financial status of the parents that need to be cared for, whether they have enough money to sustain themselves well into old age, what specific health requirements do they need in light of their deteriorating physical status and whether they require special services at home or in an institution due to their enfeebled physical condition (Davis, 1993). It is due to factors such as these that the importance of proper care planning for when the inevitable does occur becomes particularly significant and as such becomes a requirement for any conceivable measure of caring for one’s aging parents. As such this section of the report will explore the various factors that need to be taken into consideration for proper care planning and what the individual requirements of each factor will be.
Advising the Patient’s Child
The teaching plan would begin by advising the child of the parent regarding the current condition of Mrs. Nina Myers and what could possibly occur should proper intervention not be implemented. Through this process, it is anticipated that the caregiver will be able to understand the current circumstances of the patient and act accordingly.
Teaching Proper Exercise and Diet Procedures
One the caregiver has been briefed regarding the condition of the patient, it would then be necessary to explain to them the necessary exercise and dietary protocols that need to be implemented. This involves advising them regarding the amount of exercise needed per day, the types of foods that the patient can eat, the daily calorie allotment as well as other such details that they would need to know. It is expected that through this stage in the teaching procedure, the caregiver will be able to properly implement the necessary daily activities and diet that Mrs. Nina Myers would need to prevent further complications to her health.
Financial Planning and the Patient
What must first be taken into account when creating any plan for caring for elderly parents is the inherent state of their finances. The extent for any plan for assisted care is limited by the state of its finances since daily living expenses, the price of medication, utilities and other such costs must come from somewhere. While most individuals do have retirement packages built up over several years the fact remains that such packages are at times limited. It is based on this that proper care and planning must be conducted regarding the long term medication and medical support that can be given to the patient at home.
What to do in case of emergencies
In the event that a sudden emergency may occur that could complicate the health condition of the client, it would be necessary to advise the caregiver regarding standard procedures that must be followed. This entails advising them on what to do when the patient experiences chest pains, what position should the body be in to enable them to breath properly as well as other factors that they need to take into consideration prior to either transporting the patient to the hospital or for emergency respondents to be able to arrive and properly care for the patient.
Roles of a registered Nurse in caring for patients
When it comes to this particular type of patient, a case manager role is more suited for the registered nurse since it is expected that the patient will gradually improve over time should the recommended diet and level of exercise be implemented. As such, the nurse in charge of this particular would need to merely conduct regular checkups on the patient via calling the registered caregiver and ensuring that all procedures have been followed and no complications have arisen over the course of several months.
Reference List
Busby-Whitehead, J. (2012). Likelihood of Nursing Home Referral for Fecally Incontinent Elderly Patients is Influenced by Physician Views on Nursing
Home Care and Outpatient Management of Fecal Incontinence. Journal Of The American Medical Directors Association, 13(4), 350-354
Davis, B. (1993). Caring for the frail elderly: An international perspective. Generations, 17(4), 51
Folkins, A., & Longacre, T. (2013). Hereditary gynaecological malignancies: advances in screening and treatment. Histopathology, 62(1), 2-30.
Koopmans, R. M. (2013). PROPER I: frequency and appropriateness of psychotropic drugs use in nursing home patients and its associations: a study protocol. BMC Psychiatry, 13(1), 1-15.
Nay, R. (1998). Contradictions between perceptions and practices of caring in long-term care of elderly people. Journal of Clinical Nursing, 7(5), 401-408
Weltman, A. (2014). The Effect of Exercise Intensity on Endothelial Function in Physically Inactive Lean and Obese Adults. Plos ONE, 9(1), 1-7.