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Nursing Care And Management For Elderly Patient

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Questions:

1.Identify and Prioritise the Most Important Nursing Care Issues for a Client

2. Identify the Influences Impacting on the Older Person and their level of Function and Levett-Jones’ Clinical Reasoning Cycle as the tool to drive the Process of Identifying and Assessing, Implementing and Evaluating Care.
 
 

Answer:

1.Introduction

Risk of geriatric syndromes, functional decline, and chronic illness, are a threat to older adults' well being. 43% of Medicare beneficiaries report having more than three chronic conditions including heart disease, cancer, and arthritis (Federal Interagency Forum on Age Related Statistics, 2010). Reports from surveys also indicate that 42% of persons above 65years of age live with a functional limitation. In one study, the results showed that one or multiple geriatric syndromes are reported in 25% of the older population (Lee, Cigolle & Blaum, 2008). Additionally, older adults spend less of their time communicating and socializing as they advance in age (Federal Interagency Forum on Age Related Statistics, 2010). This results in an accumulation of the functional decline and interaction impairments which exacerbates the person's vulnerability (Innouye, Studenski, Tinetti, & Kuchel, 2007). This report will analyze the functional consequences in relation to Barbra's current medical situation (Hunter, 2016) and utilize clinical reasoning to map a plan toward her wellness and recovery (Levett-Jones, 2013).

Patient's Description

Name: Barbra Green

Age: 89 Years

Marital Status: Widow

Barbara experiences joint stiffness; enlarged joints and swollen feet; pain in joints especially the back, hip, fingers, and knee; limited movement on the joints; constipation; dry macular degeneration; occasional dizziness; constipation,  and weight loss. Her functionality has deteriorated which has resulted in decreased social functioning, poor living conditions, and also poor eating habits. She is likely to be non-adherent to her medications.

The age related changes include the visual deficit due to dry macular degeneration (Boyd, 2017) and constipation (Schuster, Kosar, & Kamrul, 2015).  The risk factors include poor diet, use of some specific multiple medication (polypharmacy) and diminished physical activity which are known causes of constipation among the elderly (Neri, Basilisco, & Corazziari, 2014). Caucasians are at a higher risk of macular degeneration than Hispanics or Africans (National Eye Institute, 2016) Poor diet and failure to exercise also causes fast progression of early macular degeneration. The negative consequences of the symptoms the patient is experiencing include social isolation and difficulty in performing activities of daily living

 

Information Cues

Barbara lives in a one-story building. The joint pains especially on her knees have limited her movement and it is likely that she avoids climbing the stairs in her house which may be an unkempt house. The fact that she has a vision deficit and has stopped driving means that shopping trips to the grocery store are limited or none, especially because of the existing pains on her joints that discourage her to walk. The patient also expressed her loneliness because of  the loss of her husband and also her lost contact with friends at the German Association.

Information Process

Osteoarthritis:  Osteoarthritis is common in women than in men who are 45 years and above. The disease occurs when bone cartilage wears and tears and in severe cases, it leaves bones which friction against each other. The symptoms include: mild to acute pain in the joints as well as stiffness of joints. It affects the neck, low back, hands, weight bearing joints such as feet, hips, and knees (Antipuesto, 2010).

Constipation: This is a common challenge among elderly persons with prevalence differing with settings (hospital or community). Among the population that is 65years and above and living in a community, 16% of men and 26% of women suffer from constipation (Gallegos-Orozco, Foxx-Orenstein, Sterler, & Stoa, 2012). For persons that are 84 years and above, the rtes increase to 26% and 34% for men and women respectively. For patients in long term care, the rate increases by 80% (Fleming & Wade, 2010)

 


Vision Deficit: Macular degeneration that is age related occurs when the retinal macular is damaged resulting in loss of central vision but the peripheral vision remains normal.  Dry macular degeneration is as a result of some parts of the macula getting thinner and drusen grows (Boyd, 2017).

Assessment and Interventions

Osteoarthritis

Assessment

  1. Aching pain that is deep and which is more pronounced after exercise or weight bearing; pain is relieved by rest
  2. Joint deformity or swelling
  3. Joint stiffness that lasts
  4. Heberden’s nodes on interphalangeal distal joints and Bouchard’s nodes on interphalangeal proximal joints.

Diagnosis

Chronic pain linked to deterioration of joints.

Diagnostic Evaluation

  1. X-rays show sclerosis and narrowing of joint space in affected joints
  2. Radionuclide imaging shows increased uptake in the bones that are affected.
  3. Analysis of synovial fluid shows difference in osteoathritic and rheumatoid joints.

Interventions

  1. Involved joints should be rested.
  2. Patient advised to avoid pain precipitating activities.
  3. Relieve stiffness and pain using heat applications
  4. Teach the patient body mechanics and posture that is correct
  5. Patient advised to relieve cervical pain by sleeping with a terry cloth that is rolled under the neck.
  6. When indicated, provide patient with cane, braes, or crutches, to minimize weight bearing stress on knees and hips.
  7. Advise patient to wear metatarsal support and corrective shoes.
  8. Teach patient simple motion exercises for joint mobility

Assessment

Patient should give an accurate symptoms history. Symptoms of constipation in the elderly include: abdominal pain, urinary retention, loss of appetite and nausea, overflow diarrhoea, and confusion. The risk factors include polypharmacy, alteration in fluid and nutritional intake, pre-existing diseases such as degenerative disease that affect functional and mobility status, difficulty in accessing washroom facilities (Gandel, Straus, & Bundookwala, 2013)

 

Intervention

Patients should also be offered education and advice on managing their constipation. Simple lifestyle changes, such as an increase in fluid intake, regular exercise and fiber-rich food may be effective in managing constipation (Gandel, et al., 2013)

Macular Degeneration

Assessment

  • Blurred vision
  • Visual field has central blind spot

Nursing Diagnosis

  • visual impairment
  • poor health maintenance due to lack of knowledge
  • Injury risk due to poor vision
  • Deficit in self care due to poor vision

Nursing Management

  • Once patient has a photodynamic therapy (PDT) session, she will be advised to avoid direct exposure to sunlight or any bright light for five days Watkins, (2010)

2.SMART GOAL

  • Barbara will be able to walk short distances (which will be increased with time) without experiencing discomfort and pain. The distance will be increased by 300meters every week. The walks will serve as part of her exercise routine and will help with alleviating joint stiffens as well as constipation
  • Barbara will be able to carry out her daily life activities with no assistance including preparing her own meals.
  • Barbara will regain lost weight

Taking Action

A daily routine timetable will be created which will indicate what activates to do every hour of the day. The time table will include time allocation for short walks and reminders on when to sip on water and/or other fluids. It will also show the times that Barbara needs to take her medication.

Barbara will need to purchase a 1Liter water/juice bottle. She will be required to fill it twice a day with water and after she is through sipping it, she will need to fill it with blended fruit juice. The 1l of juice and 1lof water need to be taken on a daily basis.

Home safety: Request Tracy to help in rearranging the furniture in Barbra's house to create more clear pathways to avoid any incidences of injury. Limit use of area rugs. Have the window curtains pulled all the way back to create more light. Get a talking clock. Place things that Barbara uses regularly in the same place: toothbrush, slippers, keys, shoes etc.

Evaluation

Barbara is able to take short walks on a daily basis. She can walk up and down the stairs in her house without any pain discomfort. She is able to do daily living activities with no assistance. Her house is tidier and her refrigerator and kitchen cabinets are a reflection of healthier cooking and eating. Barbara reports no dizziness and constipation. She has gained 1-2 kg in 4-6 weeks.

 

Reflection

I have a clearer understanding on the need to include regular exercising and healthy eating habits in one's daily routine starting at an early age. By eating well and exercising, age related complications such as osteoarthritis, macular degeneration, and constipation are delayed.

The next time I will enter appointment reminders in Barbara's mobile phone to ensure she comes in for checkups. I will also add a column in the timetable where the patient will need to put a star(s) after each activity to indicate her adherence. The timetable will also have incentives for each task completed. In addition, I should have given Tracy a copy of Barbara's timetable so that she can monitor Barbara's progress during her daily calls.

Conclusion

The care of elderly patients with osteoarthritis, macular degeneration, and constipation can be effectively done through lifestyle changes. The patient in this case was a widow who was living alone and had disconnected herself socially. The social isolation had resulted in poor eating habits causing her to lose weight, exacerbate her vision deficit, report slight dizziness spells, and constipation. By encouraging the patient to engage in regular exercises and healthier eating which includes daily intake of water and fiber rich fluids, the patient will be able to carry out her daily activities with minimal discomfort. She will also be able to return to her social life and reduce or completely eliminate feelings of loneliness and depression. Health promoting lifestyles including socializing, should be adopted at an early age to avoid late life complications such as discussed in this report.

 

References

Antipuesto, J.D (2010). Osteoathritis. https://nursingcrib.com/nursing-notes-reviewer/medical-surgical-nursing/osteoarthritis/ Accessed: 03rd April, 2017

Boyd, K (2017). What is Macular Degeneration? American Academy of Opthamology. https://www.aao.org/eye-health/diseases/amd-macular-degeneration. Accessed: 03rd April 2017

Federal Interagency Forum on Aging-Related Statistics. Federal Interagency Forum on Aging-Related Statistics. Washington DC: U.S. Government Printing Office; Jul, 2010. Older Americans 2010: Key Indicators of Well-Being.

Fleming V, Wade WE. A review of laxative therapies for treatment of chronic constipation in older adults. Am J Geriatr Pharmacother. 2010;8(6):514–50Gallegos-Orozco JF, Foxx-Orenstein AE, Sterler SM, Stoa JM. Chronic constipation in the elderly. Am J Gastroenterol. 2012;107(1):18–25. Epub 2011 Oct 11

Gandell D, Straus SE, Bundookwala M, Tsui V, Alibhai SM. Treatment of constipation in older people. CMAJ. 2013;185(8):663–70. Epub 2013 Jan 28. 

Hunter, S. (Ed). (2016). Miller’s nursing for wellness in older adults (2 nd Australia and New Zealand ed.) North Ryde, NSW: Lippincott, Williams and Wilkins.

Innouye SK, Studenski S, Tinetti ME, Kuchel GA. (2007). Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept. Journal of American Geriatrics Society. ;55(5):780–791.

Lee PG, Cigolle C, Blaum C. (2009)The co-occurrence of chronic diseases and geriatric syndromes: The health and retirement study. Journal of the American Geriatrics Society.57(3):511–516.

Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Frenchs Forest, NSW: Pearson.

National Eye Institute (2016). Facts About Age-Related Macular Degeneration. https://nei.nih.gov/health/maculardegen/armd_facts. Accessed: 03rd April, 2017.

Neri L, Basilisco G, Corazziari E.(2014) Constipation severity is associated with productivity losses and healthcare utilization in patients with chronic constipation. United European Gastroenterol J. 2:138–47.

Schuster, B. G., Kosar, L., & Kamrul, R. (2015). Constipation in older adults: Stepwise approach to keep things moving. Canadian Family Physician, 61(2), 152–158.

Watkins, S (2010). Management of older people with dry and wet age-related macular degeneration. DOI: 10.7748/nop2010.06.22.5.21.c7793

OR

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