Discuss about the Care of the Older Patient for Nursing Management.
The present paper will discuss the nursing management of an aging patient in reference to the theories of aging. To clearly understand these concepts a case study of an elderly patient recently interviewed will be used. Their illness pathophysiology and comorbid conditions will be discussed and linked to theories of aging that have been put forth. The impact of the disease on the patient will be addressed with some ethical and legal issues as pertaining to their care will be established. Lastly, evidence-based approaches to the care of the patient will be discussed. This is with an objective to help the nursing care team accommodate the elderly in quality care provision using evidence as a guarantee.
The patient is R.S, an eighty-three-year-old female. She is a retired hotel attendant and had worked for over forty years in the hotel and hospitality industry. She currently owns a chain of small-scale restaurants that she started with her husband. She is a widow with six children, the youngest being twenty-nine years old. She presented to the cardiac clinic with complaints of dyspnea, easy fatigability, and chest pain. A diagnosis of stable angina due to coronary heart disease was made on history and confirmed by a coronary angiogram. She is a known hypertensive for the past ten years and was on medication. She also complained of stiff joints and reduced range of motion in her joints especially the lower limbs. An impression of ongoing arthritis was made. She, however, is obese but not diabetic. Her past medical history revealed a past history of angina, fracture of the left femur due to a fall from a height and a previous surgery for cataracts. Her social and family history showed that she lived with an assistant who was hired by her eldest son to take care of her needs. She was not a smoker and did has never used alcohol before. Her husband died when she was seventy-two years old from a myocardial infarction. She has fears that she will succumb to the same fate since she has the same symptoms her husband exhibited.
Coronary heart disease (CHD) is a disease caused by defective, narrowed coronary vessels usually due to atherosclerosis (Colledge, Walker & Ralston, 2013). The typical presentation is angina, which is acute chest pain due to myocardial ischemia, myocardial infarction and heart failure (Glynn & Drake, 2014). The patient presented with stable angina, a coronary syndrome due to fixed atheromatous stenosis of one or more coronary vessels causing ischemia.
An atheroma is an aggregation of lipid plague in the vessel wall. It forms when an inflammatory reaction in the vessel wall recruiting macrophages forming foam cells. There is then an intracellular lipid accumulation as the defect grows larger. In response to the macrophages, the smooth muscles of the vessel wall media migrate to the intima covering the lipid core with smooth muscle (Chilton, 2013). This covering although narrowing the vessel, stabilizes the atheroma forming a fixed atheromatous plague. The atheroma ages in that angiogenesis lead to the provision of blood supply and deposition of calcium (Chilton, 2013). A fibrous cap forms to top the atheroma. The edge of this cap is important in the pathogenesis of the acute coronary syndromes as they are prone to rupture. In the end, the plague will consist of a lipid core with necrotic tissue capped by a fibrous cap (Chilton, 2013).
If the vessel occlusion is large enough then the blood supply to the part of the heart distal to supplying vessel experiences ischemic changes. The initial one is angina, a form of chest pain. it is a syndrome rather than a disease. There is an imbalance between myocardial oxygen supply and demand. Due to fixed atheroma, the chest pain is predictable following sessions of exertion. This is explainable as the heart oxygen demands rise on any physical activity as it tries to maintain whole body perfusion. This pain is generally relieved by rest which reduces demand. However, this syndrome occurs in a continuum as the atheroma can become compromised or rapture, giving rise to unstable angina which is worse and is not relieved by rest. On the extreme end of this continuum is myocardial infarction which occurs when there is total occlusion of blood supply leading to ischemic death of myocardium, the so-called heart attack (Colledge, Walker & Ralston, 2013).
The contributing factors to coronary heart disease are many. They include age, hypertension, diabetes mellitus, hyperlipidemia or obesity, smoking, chronic kidney disease, sedentary lifestyle involving intake of unsaturated fats and lack of aerobic exercise, and stress (Daviglus et al, 2012). These are termed cardiovascular risk factors and either increase the chance of forming an atheroma or modify the bodies way of dealing with it. Obesity and hyperlipidemia increase the body’s low-density lipoprotein levels which are involved in atheroma formation. Smoking cessation is the single most important modifiable risk factor for heart disease and cessation has been associated with the low chance of coronary heart disease (Daviglus et al, 2012). Hypertension is associated with hardening of vessels and ventricular hypertrophy. Hardened vessels easily occlude with cholesterol and an enlarged heart leads to increased oxygen demand. Another risk factor is social stress (Daviglus et al, 2012).
Theories of aging
The theories of aging try to make sense of the aging process and its implications (MacNee, Rabinovich, & Choudhury, 2014). The psychosocial theories of aging include the continuity theory, disengagement theory, and the activity theory. The activity theory of aging was introduced in 1961 by Havighurst and postulates that life satisfaction can be achieved if one maintains the normal activity of middle years (Diggs, 2015). He postulated that an aging individual has the same psychological needs as those of a middle-aged individual but due to social disruption lie isolation, retirement and loss of ability to participate may make the older individual lose their identity and self-esteem. A person will be considered to age well if they continue with the activity of youth or find innovative ways to replace them with new ones.
The disengagement theory postulates that as one ages they naturally withdraw from society and social norms (Johnson & Mutchler, 2014). It assures that this is normal for an aging person and should be expected. It is made up of several postulates that try to justify why older people disengage: the expectation of death, fewer contacts, evolving ego, and loss of roles. This theory encourages a sedentary lifestyle as the patient is isolated from most situations. The continuity theory of aging postulates that despite the aging process personality and basic behavior patterns remain constant in an individual.
Miller, (2004) developed the functional consequences theory that helps to explain the correlation between age and health. It provides a framework for the promotion of the wellness in older patients (Campbell & Hughes, 2016). It aids the nurses in focusing reducing the negative effects that are age-related and removing the risk factors so as to improve the wellness of the elderly patients. It helps the nurses to recognize that the older adults have a potential for growth. With this, they are able to come up with the nursing diagnosis that cultivates a sense of dignity and value. Miller's theory enables nurses to be holistic when dealing with the aged. It focusses on age-related changes, environmental factors, modifiable risk factors and unmodifiable risk factors (McMahon & Fleury, 2012). It is termed the nursing theory of aging. In cardiovascular disease, age-related changes include thickening of valves and stiffening of musculature due to deposition of calcium. This reduces the cardiovascular reserve and it can’t effectively compensate large alterations in function. The vessels become stiffer and more predisposed to injury, the so-called vascular theory of aging.
Impact of the condition on patient life.
The impacts of this condition on the patient’s life are large. Health-related quality of life (HRQL) is a measurable concept that addresses the individual’s responses to living with the condition taking in consideration recreational activities, social, emotional, sexual, personal and occupational relationships (Thompson & Yu, 2013). Measurement is in two modules, generic and disease-specific. Some tools relevant to our patient include Seattle Angina questionnaire and Cardiovascular Limitations and Symptoms Profile (CLASP) (Thompson & Yu, 2013). With exertional dyspnea and angina, daily activities are restricted and quality of life is greatly reduced. Some cases require hospitalization further complicating their life. The economic burden of treating heart disease is substantial and without a good socioeconomic support, it might prove difficult to manage the chronic condition (Mory?, Bellwon, Höfer, Rynkiewicz, & Grucha?a, 2016). The patient will have diet restriction, social restrictions including stopping alcohol and smoking, exercise restriction thus denying them a chance to enjoy their favorite activities and the psychological stress associated with the chronicity (Thompson & Yu, 2013).
Ethical issues in the management of older patients.
Older patients may face discrimination, victimization or disregard for their dignity due to their perceived or actual disability or helplessness (Hinkle & Cheever, 2013). The basic ethical principles of medical practice should still apply to the care of the elderly including autonomy, beneficence, justice, and non-maleficence (Kane, Ouslander, Abrass, & Resnick, 2013). Autonomy refers to the patients right to control one’s care (Kane, Ouslander, Abrass, & Resnick, 2013). It is the principle most emphasized in the concept of patient-centered care where the patient has the right to choose the treatment options and make an informed decision. Informed consent to be sought before any procedure is sought. Beneficence refers to the nursing care provided that is towards doing so and not causing harm (Kane, Ouslander, Abrass, & Resnick, 2013). All medical decisions should be to the benefit of the patient. It is the duty of the care provider to inform the patient the best possible care plan. Non-maleficence simply refers to the principle of doing no harm (Kane, Ouslander, Abrass, & Resnick, 2013). No decision made should compromise on the safety and well-being of the patient. Justice refers to the fair, equitable and appropriate distribution of care in the society (Kane, Ouslander, Abrass, & Resnick, 2013). The elder patient should receive the same level and quality of care and consideration as anyone else.
The appropriate model of care
A care plan has to be implemented to take into consideration the multimorbidity of her conditions, fragility, polypharmacy, and cognition (Pi & Hu, 2016). She is a diagnosed hypertensive with obesity and now diagnosed stable angina with signs of arthritis. The management should be multidisciplinary to maximize expertise and competency. The team should include primary care, geriatricians, cardiology specialists, physical therapy, nursing team and nutritionist. According to Wee, Burns, & Bett, (2015), the typical strategy used should be to access cardiovascular risk in conjunction with comorbid conditions, cardiac management tailored to fit the diagnosis and rehabilitative care to improve functionality and finally preventive measures to avoid an acute coronary syndrome that can be immediately fatal.
Management of stable angina relies on the risk assessment to decide on the need for surgical revascularization (Wee, Burns, & Bett, 2015). Risk assessment takes into account risk factors including hypertension, diabetes, smoking, clinical evaluation using stress echocardiography, ECG, lab tests and coronary angiography (Kavousi et al, 2012). Medical management involves pain relief for angina using short-acting nitrate drugs, antianginal medication using beta blockers and calcium channel blockers (Jarvis & Saman, 2017). Event prevention using aspirin is also recommended. Lifestyle modification plays an important role in cardiovascular risk reduction. They include cessation of smoking, control of blood pressure, eating a healthy diet, weight reduction, screening for sleep apnea and vaccination for influenza (Wee, Burns, & Bett, 2015).
In conclusion, the management of an older patient is as important as any other age group. The management has to take into consideration the ethical and legal implications and still be precise. The case study presented was of a patient with stable angina, a syndrome indicative of coronary heart disease due to atherosclerosis. The psychosocial theories of aging which include the activity theory, continuity theory, and disengagement theories link to the causation of coronary heart disease. Miller’s functional theory further outlays aging and health as a link that can be modified for good wellbeing of the elderly patient.
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