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Analysis of Geriatric Care Needs Jie LiFerris State UniversityAbstractThis paper used the nursing process to identify an older Asian American woman’s health care needs and developed appropriate plans to meet the client’s health care needs. It began with the client’s complete health assessment. The three nursing diagnoses were made based on the assessment. I then created plans to achieve desired outcomes. I would evaluate the plans to ensure the action plan is being implemented and modify the action plan as necessary. A policy is suggested to better meet needs of the Asian American elderly.Analysis of Geriatric Care Needs The aging of America promises to affect all areas of society. One prominent area is health care. The demand for elder care is continuously increasing. Therefore, it is important to provide quality care for this special group to meet their health care needs. The goal is to enhance the well-being of older adults.Assessment According to Fulmer (2007), the SPICES instrument can be used to assess common problems among the entire elderly population in all clinical settings. SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention: S is for sleep disorders, P is for problems with eating or feeding, I is for incontinence, C is for confusion, E is for evidence of falls, and S is for skin breakdown. I assessed an elderly female who I have known for a long time. Mrs. W. was a school teacher. Mrs. W. just turned 70. She and her husband both are Asian Americans. They still live at home. The two do not get along, but they have been together for more than 40 years. They have a fixed home helper come twice a week to help do chores. Mrs. W. is able to perform activities of daily living (ADLs) on a daily basis. She has history of chronic back pain, urinary incontinence, and hypertension. She stays at home most of the time due to chronic pain and feels shame associated with urine leakage. Chronic diseases lead her to become physically inactive. First, I assessed Mrs. W.’s sleep habits and pattern. Mrs. W. states, “I do not take naps during the day. I have no difficulty falling asleep. I go to bed at 10:30pm, fall asleep at 11pm, and wake up early at 5am. I have approximately 6 hours sleep every day. However, chronic back pain causes me to awaken sometimes at night.” Medical problems may contribute to sleep disturbance. Mrs. W.’s chronic back pain affects the quality of her sleep. Waking up at night results in daytime fatigue and low productivity. Next, I assessed Mrs. W.’s eating habits. Mrs. W. has no chewing or swallowing problems. Her diet is restricted to low cholesterol and low salt because of obesity and hypertension. She has a fairly good appetite. She usually has four or five smaller meals a day. She eats vegetables, fruits, and rice every day and fish and certain meats four times a week. She drinks 8 glasses of fluids to keep the body hydrated. She also takes 1000mg of calcium and 400 units of vitamin D each day. I think Mrs. W. receives the good nutrition an elderly person needs. I then asked Mrs. W. whether she has incontinence. Mrs. W. states, “I lost bladder control after childbirth. I was just leaking out urine occasionally. The problem did not go away by itself. I did not begin to have real problems until late 40s. I had to routinely use panty liners in my late 40s. Urine leakage has begun to occur during coughing or sneezing. As I age, I noticed that the frequency of incontinence episodes and the amount of urine loss had increased.” She obviously experiences stress urinary incontinence. During the interview, Mrs. W. was able to respond appropriately to my questions, and her memory is intact. I had a chance to talk to Mrs. W.’s husband. He thinks that his wife recently has no change in cognitive function. So Mrs. W. does not need to have a thorough assessment to rule out dementia or delirium. Dementia, delirium, and depression have been called the three D’s of cognitive impairment because they occur frequently in older adults (Ebersole, Hess, Touhy, Jett & Luggen, 2008, p. 554). However, it is necessary to use the Geriatric Depression Scale (see Appendix) to screen for depression. Depression is commonly seen in a person experiencing chronic pain (Disorbio, 2011, para. 2). Most people with incontinence suffer social embarrassment. Many become depressed and limit their activities away from home, often becoming socially isolated and lonely (Vigod, & Stewart, 2005). Chronic pain and urinary incontinence Mrs. W. suffers can put her at higher risk for depression. Her score was 6 on the Geriatric Depression Scale. A score of 6 indicates mild depression. To assess fall risks, my initial assessment is to measure Mrs. W.’s ability to perform activities of daily living (ADLs). Mrs. W. was able to perform personal care independently, such as feeding, transferring, dressing, and toileting. She was able to prepare her meals. However, Mrs. W. told me that she fell at home last year. Her slipper got stuck, causing her to lose balance. Fortunately, she did not have severe injury. However, she states, “I am afraid of falling after experiencing a fall”. Statistically, factors, such as age, past history of falling, medication use and physical conditions, increase the likelihood that a patient will fall (Eldridge, 2007, p. 28). Mrs. W.’s age, past history of falling, improper footwear, chronic illness, and medication use put her high risk for fall. Last, I performed a total body assessment from head to toe to see if Mrs. W. has any potential or actual skin breakdown. I paid particular attention to the areas at increased risk secondary to pressure, friction, or moisture: abdominal folder, buttocks/perineum sacrum/coccyx, and heels. I did not find any potential or actual skin breakdown. Among biological theories of aging, wear and tear theory best explains Mrs. W.’s aging process. “The wear and tear theory proposes that errors result when cells wear out over time because of continued use. Cells are aggravated by the harmful effects of internal and external stressors, which include injurious metabolic by-products. These may cause a progressive decline in cellular function and the death of an increasing number of cells” (Ebersole, et al. 2008, p. 28). The information collected from Mrs. W. is telling me that Mrs. W.’s internal and external stressors affect her negatively. External stressors include adverse physical conditions, such as chronic back pain and urinary incontinence, and stressful psychological environments, such as disrupted marital harmony. Internal stressors are more psychological, such as intense worry about incontinent urine odor, fear of falling, and loneliness. Over time, repeated stressful situations put a strain on the body that may contribute to a progressive decline in cellular function.Nursing Diagnoses Base on the assessment information, three related nursing diagnoses for Mrs. W. are powerlessness, stress incontinence, and risk for falls. Planning Mrs. W. should have a home health nurse. The home health nurse would coordinate with Mrs. W, her family members, her physician, and community agencies to develop a plan of care for Mrs. W. The goals for Mrs. W. are to verbalize ability to control situations, report a reduction of stress incontinence, and reduce the risk of falls. According to the 2000 U.S. census, Asian Americans make up 4.3% of the total U.S. population. However, this number represents an increase of 63% from the 1990 census, making Asian Americans the fastest growing of all the major racial/ethnic groups in the U.S. In addition, it is generally accepted that culture influences health practices and might affect health care delivery. Therefore, it is important for health care providers to train and gain knowledge of different cultures to provide culturally competent care to meet the expected increased demand.Implementation “Powerlessness is a state in which an individual or group perceives a lack of personal control over certain events or situations that affects outlook, goals, and lifestyle” (Carpenito-Moyet, 2004, p. 571). Factors that contribute to Mrs. W.’s powerlessness include chronic back pain, depression, lack of knowledge, and inadequate coping mechanisms. Intervention should be focused on reducing these adverse contributing factors. Intervention should start with pain management. As a patient advocate, the nurse should contact Mrs. W.’s primary care physician and discuss Mr. W.’s pain condition with the primary care physician. Mrs. W.’s primary care physician would be able to provide a referral for her to go to a pain clinic to see a pain specialist. Lifestyle changes, physical therapy, in addition to medication, these can also bring pain relief. Mrs. W. will need to make lifestyle changes, such as: eat a balanced diet, exercise regularly to build her strength and health. According to the Physical Activity Guidelines for Americans announced by U.S. Department of Health and Human Services (HHS) (2008), older adults need at least 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week and muscle-strengthening activities (i.e., general gardening) on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, ?shoulders, and arms). Mrs. W. can break it up into smaller chunks of time during the day, as long as she is doing physical activity at a moderate or vigorous effort for at least 10 minutes at a time. Chronic pain usually results in reduced activity level. Mrs. W. even may not meet the guidelines because of her chronic pain. She should be as physically active as her abilities and conditions allow. Walking is the simplest exercise any older adult can do. Schedule her day so that she is most active when she has the most energy. Start slowly and gradually increase her level of activity. The nurse should remind Mrs. W. to take her medicines as prescribed. Keep her appointments with her doctor, especially if she has constant chronic pain. Encourage her to join a chronic pain support group. A support group is made up of people with similar experiences who can understand each other’s feelings and provide comfort. A support group can keep Mrs. W. from feeling isolated and alone. Being around others who share the same problem can help her and her family learn how to accept and manage chronic pain. Culture affects our health through our beliefs, values and behaviors. “A study of Chinese Americans revealed that first- and second-generation Chinese immigrants tend to use Chinese therapies to treat illness” (Pelletier, 2000, para. 4). I thought acupuncture may be a good choice for Mr. W. According to the World Health Organization (2002), acupuncture may be effective as an alternative treatment for many pain-related conditions, including: headache, migraines, low back pain, neuralgia, and rheumatoid arthritis. Sixteenth century Chinese doctors believed that illness was due to an imbalance of energy in the body. Acupuncture involves inserting very thin stainless steel needles to the body's 14 major meridians to resist or overcome illness by correcting these imbalances. Living with chronic pain is a tremendous burden. That, over time, will result in feelings of helplessness, hopelessness, and depression. People in pain may become more depressed and this can actually make the pain worse. So, depression can make chronic pain harder to treat. Treat depression early, before they get worse and become harder to treat. Most of people with depression can be treated with antidepressant medication. As scientists have done more and more research on depression, we now know that effective coping mechanisms may be beneficial to people with chronic pain and depression. Ways you can cope include: talking to someone you trust; joining a support group; relaxation techniques; taking care of your health by eating right, exercising and not smoking; being honest with those around you. “Risk for falls is a state in which a person has increased susceptibility to falling” (Carpenito-Moyet, 2004, p. 454). According to Centers for Disease Control and Prevention (CDC) (2010), one in three Americans age 65 and older fall each year, and 30 percent of falls cause injuries requiring medical treatment. Fall-related injuries recently accounted for 6 percent of all medical expenditures for people age 65 and older. Almost half of all falls occur at home. A good place to start is in the home. Therefore, the nurse should inspect each room in Mrs. W.’s home. Be sure Mrs. W. has adequate lighting throughout her house, has railings in hallways and grab bars in the bathroom, installs nonslip a rubber mat on the floor of the tub or shower, uses night lights in hallways, bathrooms and bedrooms, and organizes the house to create plenty of room to walk freely. Patient education is critically important. Patient education is to raise awareness of fall risk and teach prevention measures. The nurse should educate Mrs. W. and her family about fall risk factors and interventions to lessen the impact of these risk factors. Among these risk factors, environmental risk factors need to be taught first. Many accidents result from environmental hazards, such as dimmed lights and wet floors. Accidents may not be predictable, but they are preventable with attention to environmental risk factors. Therefore, the nurse must teach Mrs. W. and her family the general safety precautions that apply in every situation, such as cleaning up spills and eliminating clutter. The nurse should advise Mrs. W. about wearing flat, nonslip footwear for safety. The nurse also needs to teach Mrs. W. what medical conditions and what medications could contribute to the tendency to fall. Research has shown that people having more than one chronic disease of any kind are more likely to fall, and medical conditions, such as vascular disorders, neuromuscular disorders, musculoskeletal disorders, sensory loss, lung disease, and bowel or urinary urgency, increase fall risk (Cottee, 1999). Patient who take more than four medications are statistically more likely to fall than those who take fewer drugs. Medications, such as sedatives, antidepressants, antipsychotics, anticoagulant, and benzodiazepines, increase fall risk (Boddice & Kogan, 2009). Therefore, it is extremely important to treatment overall medical conditions and reduce overall medication taken when possible. “On the whole, there is sufficient evidence that exercise reduce the risk of falling” (Eldridge, 2007, p. 45). Mrs. W. should follow the 2008 Physical Activity Guidelines for Americans as mentioned above. Studies have shown that about one-third of patients develop a fear of falling after an incident fall. Furthermore, patients who reported a fear of falling experience a greater increase in balance and cognitive disorders over time, resulting in a decrease in mobility level, which is, in itself, a risk factor for falls (Honaker, 2006). Education along with exercise may improve Mrs. W.’s confidence and reduce the fear of falling. Mrs. W. needs to be reminded that she is on a number of medications, having chronic illness, and physically inactive, all of which can make her weaker and more susceptible to falling. Although it may not be possible to prevent every fall, most falls are preventable. Each fall prevented is one less potential injury, fracture, head trauma, or death. “Stress incontinence is a state in which a person experiences an immediate involuntary loss of urine with an increasing in intraabdominal pressure” (Carpenito-Moyet, 2004, p. 806). Mrs. W. stated that small amounts of urine were lost with physical exertion, coughing or sneezing. Consistently and correctly performing pelvic floor exercises (kegel exercises) can reduce the severity of stress incontinence for many women; however, improvement is not immediate and requires adherence to the regimen (Ignatavicius & Workman, 2006, p.1690). Kegel exercises can strengthen the pelvic muscles involved in urination. Doing these exercises correctly and doing them regularly are key in succeeding with this method. The nurse should teach Mrs. W. how to self-assess whether exercises are being done correctly. This can be done by having her place a finger in her vagina so that she can feel the pelvic muscles contract. Also, to prevent leakage when she feels a sneeze or cough coming, try a Kegel by tightening her pelvic floor muscles. To perform pelvic muscle exercises, tighten your pelvic muscle for a count of 10, then relax for a count of 10. Do this exercise 15 times while you are lying down, sitting up, and standing (a total of 45 exercises). This should take 3 to 4 minutes for each set of 15 exercises. Begin with 45 exercises a day in three sets of 15 exercises each. Encourage Mrs. W. to do this twice a day. Reassure Mrs. W. that she will notice improvement in her control of urine after she has been doing them for 3 months. Weight reduction is helpful for obese clients because stress incontinence is made worse by increased abdominal pressure from obesity (Ignatavicius & Workman, 2006, p.1690). The physical and psychological effects of urinary incontinence on the affected women are tremendous. Physical conditions linked to incontinence include infection, skin irritations, falls, and sleep disturbances. For example, the regular pad use by these women and constant contact of urine with the vulva cause unbearable skin conditions. It is important to regularly and gently cleanse perineal area to avoid skin damage and urinary tract infection. Most patients are ashamed and embarrassed by the condition. They are too embarrassed to talk to their health-care provider about it. They withdraw from social activities and become depressed. The nurse should communicate with Mrs. W.’s primary care physician to address the problem. Evaluation The home health nurse should visit Mrs. W. in six weeks to see if Mrs. W. achieves desired outcomes. Mrs. W. should report a sense of hope. She should feel more confidence in daily life, such as how to deal with pain, knowing when and where to seek for help. She should keep on doing exercises recommended by HHS. She should actively participate in the community activities. Mrs. W. should report a reduction of stress incontinence evidenced by reduction in the use of panty liners. The home health nurse must regularly reevaluate Mrs. W.’s needs and revise the plan of care as needed.Policy “Life expectancy and overall health have improved in recent years for most Americans.?However, not all Americans are benefiting equally.?There are continuing disparities in the burden of illness and death experienced by blacks or African Americans, Hispanics or Latinos, American Indians and Alaska Natives, and Native Hawaiian and other Pacific Islanders, compared to the U.S. population as a whole” (CDC, 2007). While we realize the importance of diminishing health disparities, we need to have policies and programs available for minorities.?In Mrs. W.’s case, I can see several barriers that hinder effective implementation of the plan. The barriers include language barriers, financial concern, lack of resources such as books and journals, and lack of support. The policies and programs need to help minorities to overcome these barriers.Conclusion In general, older adults are very vulnerable. They have special needs. Also, it is important for health care providers to assess the health needs of individual clients. Interventions should be individualized to meet the unique needs of each client. Health care providers should collaborate with the client and the client’s family to ensure effective and timely implementation of the care plan. The ultimate goal is to improve older adults’ health and quality of life.ReferencesBoddice, S. D., & Kogan, P. (2009). Research on patient safety: falls and medications. Home Healthcare Nurse, 27(9), 555-560. doi:10.1097/01.NHH.0000361928.45044.64Carpenito-Moyet, L. J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.Centers for Disease Control and Prevention. (2007). About minority health. Retrieved from for Disease Control and Prevention. (2010). Falls among older adults: An overview. Retrieved from , M. (1999). Recognizing medical reasons for falling. Physiotherapy Theory & Practice, 15(2), 135-140. Retrieved from CINAHL database.Disorbio, J. M. (2011). Psychological factors and pain. Retrieved from . articles/703/psychological-factors-and-painEbersole, P., Hess, P., Touhy, T. A., Jett, K., & Luggen, A. S. (2008). Toward healthy aging: Human needs & nursing response (7th ed.). St. Louis, MO: Mosby.Eldridge, C. (2007). Evidence-based falls prevention: A study guide for nurses (2nd ed.). Marblehead, MA: HCPro, Inc.Honaker, J. (2006). A team approach risk of falling assessment and remediation program for community dwelling older adults with a fear of falling and balance disorders. Retrieved from CINAHL database.Ignatavicius, D. D., & Workman, M. L. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). St. Louis, MO: Elsevier Saunders.Pelletier, K. R. (2000). Medical use of traditional Chinese medicine. Retrieved from http:// TBAM/excerpts/100-Medical_Use_of_T.htmlThe World Health Organization. (2002). Acupuncture: Review and analysis of reports on controlled clinical trials. Retrieved from /9241545437.pdfU.S. Department of Health and Human Services. (2008). Physical Activity Guidelines for Americans. Retrieved from , S. N., & Stewart, D. E. (2005). Major depression in female urinary incontinence. Psychosomatics, 47, 147-151. doi:10.1176/appi.psy.47.2.147Wallace, M., & Fulmer, T. (2007). Fulmer: An overall assessment tool for older adults. Retrieved from Depression Scale: Short FormChoose the best answer for how you have felt over the past week:1. Are you basically satisfied with your life? YES / NO2. Have you dropped many of your activities and interests? YES / NO3. Do you feel that your life is empty? YES / NO4. Do you often get bored? YES / NO5. Are you in good spirits most of the time? YES / NO6. Are you afraid that something bad is going to happen to you? YES / NO7. Do you feel happy most of the time? YES / NO8. Do you often feel helpless? YES / NO9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO10. Do you feel you have more problems with memory than most? YES / NO11. Do you think it is wonderful to be alive now? YES / NO12. Do you feel pretty worthless the way you are now? YES / NO13. Do you feel full of energy? YES / NO14. Do you feel that your situation is hopeless? YES / NO15. Do you think that most people are better off than you are? YES / NOAnswers in bold indicate depression. Score 1 point for each bolded answer.A score > 5 points is suggestive of depression.A score > 10 points is almost always indicative of depression.A score > 5 points should warrant a follow-up comprehensive assessment. ................
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