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Danielle EloreAnalysis of Geriatric Care NeedsFerris State UniversityAbstractThis document will be an assessment of B.R. who is a 77 year old man admitted to the hospital with increased confusion and agitation. Multiple assessment scales will be used on B.R. to indicate any medical concerns. The nursing process will be used on B.R. to identify diagnoses and a plan of care with nursing interventions that will help to identify the issues of hopelessness, increased risk of bleeding and caregiver strain. The plan will be evaluated and then policy implications will be discussed. Analysis of Geriatric Care NeedsAn analysis will be made about a case study of a 77 year old man, B.R., with dementia that also suffers from depression and is a fall risk with a risk of bleeding secondary to warfarin use (Oh, n.d.). A thorough assessment will be done on B.R. and three nursing diagnoses will be prepared based on that assessment. Then a plan of care with nursing interventions will be planned and implemented to help with B.R.’s diagnoses. This process will then be evaluated for measurable outcomes. Based on the information provided within this process, policy implications and changes will be proposed. AssessmentB.R. is a 77 year old man that lives with his wife in Kingsley, Michigan. B.R.’s height is 183 centimeters and weight is 109 kilograms. B.R. was diagnosed with Alzheimer’s dementia in 2012. His other medical history includes hypertension, hyperlipidemia, coronary artery disease with a coronary artery bypass graft in 2010, atrial fibrillation, osteoarthritis and benign prostatic hypertrophy. His surgical history includes coronary artery bypass graft, bilateral total knee arthroplasties and transurethral resection of the prostate. He has no known allergies. His medications prescribed include Lisinopril, Atorvastatin, Plavix, Warfarin, Metoprolol, Aricept and extra strength Acetaminophen as needed for pain. B.R. presents to the hospital after becoming mildly agitated and having intermittent violent outbursts towards his wife. B.R. is also becoming increasingly confused at night and not sleeping well. B.R.’s wife would like to be able to take him home upon discharge if his mood can be regulated. Upon initial nursing assessment in the hospital, B.R. is alert, disoriented to time and place, agitated, however is calmer with his wife at the bedside. B.R. denies pain. Heartrate is regularly irregular with EKG showing atrial fibrillation. Lungs are clear bilaterally. Bowel sounds are present in all quadrants. B.R. states he is passing gas and bowel movements are regular per the wife. B.R. is incontinent of urine more often than not per the wife and wears an adult diaper most of the time and especially at bedtime. Skin is mostly dry and intact however red and excoriated skin is noted in the perineal area. A Braden skin assessment was completed on B.R. (see Appendix A) which showed he is at little risk of developing a pressure ulcer (Pillow Paws, n.d.). B.R. is noted to have an unsteady gait, therefore a Heinrich II fall risk assessment was completed (see Appendix B) which showed B.R. is a high risk for falls (Walla Walla Community College, n.d.). This is of increased concern because B.R. is taking warfarin for his atrial fibrillation, therefore he is at a high risk for bleeding and risk of injury is greater if a fall were to occur. B.R.’s wife states that “he just hasn’t been himself lately. He yells a lot and gets mad at me when I try to tell him what is going on. He also just lays in bed for a lot of the time which is making it harder for him to walk.” A Geriatric Depression Scale has been done on B.R. (see Appendix C) that showed that B.R. is depressed (Practicing Physician Education in Geriatrics, n.d.). The wife is very upset and overwhelmed that her husband has been declining and is eager to get him help. Fluoxetine was started by the admitting physician as well as PRN Zyprexa. He will be followed medically and proper referrals will be made and then returned home if his mood is stabilized and is able to be cared for appropriately without a heightened risk for falls so that the patient can be safe at home. According to Touhy and Jett (2012) the activity theory of aging states that continued activity is an “indicator of successful aging” and the focus is “the individual’s need to maintain a productive life for it to be a happy one” (p. 38). B.R.’s life has gone through a lot of changes lately. According to his wife, he has not been himself and has not wanted to do much and he is becoming agitated more often. More will need to be done to allow B.R. to have continued activity so that he can partake in successful aging. DiagnosesAccording to Oh (n.d.) patients suffering from dementia may not always present with typical symptoms, oftentimes agitation is a symptom of depression in a person suffering from dementia. Therefore, the first nursing diagnosis to be made is: Hopelessness related to depression, cognitive deficits and confusion as evidenced by increasing agitation, violent outbursts and dementia (Carpenito-Moyet, 2008). As B.R. is becoming weaker, his fall risk is increasing. B.R. is prescribed warfarin to help prevent blood clots that could be the result of his atrial fibrillation. If B.R. were to fall he would have an increased risk of injury and risk of bleeding. The next nursing diagnosis is: Risk for injury related to weak and unsteady gait, confusion, bleeding as evidenced by use of anticoagulants and increased fall risk (Carpenito-Moyet, 2008). B.R.’s wife is this patient’s caregiver. She has been under a lot of pressure lately while caring for B.R. and dealing with his changing moods, increased agitation and violent outbursts. The final nursing diagnosis is: Caregiver role strain related to unrelenting or complex care requirements secondary to chronic mental illness as evidenced by increased agitation and violent outbursts exhibited by the patient (Carpenito-Moyet, 2008). PlanningTo address B.R.’s hopelessness nursing diagnosis, medications must be administered and taken to help regulate B.R.’s mood and depression, also to help him sleep through the night. He can also become involved in the community once his mood regulates, finding out what activities he enjoys doing would be helpful. He can be set up with a counselor to talk to about his feelings; training for the wife to have effective communication with B.R. is also something that would be helpful. The goal is for B.R. to express his feelings about his life and hopefully share some optimism about the present and future (Carpenito-Moyet, 2008). The nurse should speak to the physician about the administration of warfarin to prevent blood clots and see if the risk versus benefit of the drug can be identified or if there are other options for medical management of his atrial fibrillation. Physical and occupational therapy should also be consulted to help strengthen B.R. so his gait becomes steady. B.R.’s wife should be referred to a counselor or a support group to help with the strain of caregiving. Active listening and communication with the nurse may also be very helpful to ease some of the wife’s worries. Also, once B.R. becomes stronger and with the help of other interventions and medications his affect and behavior should improve, then caregiving may not be such a hardship. ImplementationParticipation of the nurse, wife and other specialties will be used to develop interventions to assist in resolving the problems listed in the nursing diagnoses. These interventions will be outlined in this section. Hopelessness related to depression, cognitive deficits and confusion as evidenced by increasing agitation, violent outbursts and dementia.Support and encourage active listening and communication by the nurse upon admission to the hospital that will last through discharge. Encourage verbalization with the patient about why hope is significant in their life.Assist with identification of sources of hope.Convey empathy to promote these verbalizations (Carpenito-Moyet, 2008). Refer patient to counseling services upon admission to the hospital. Involve social work. Assess spiritual need and refer to spiritual consultation upon admission to the hospital. Assess for B.R.’s like and dislike of activities. Educate B.R. and his wife about medications purpose and side effects upon admission to hospital. Involve pharmacist if additional education is required. Make sure discharge medication educated is thoroughly communicated with B.R. and his wife. Risk for injury related to weak and unsteady gait, confusion, bleeding as evidenced by use of anticoagulants and increased fall risk.Assess fall risk using Heinrich II fall risk assessment scale upon admission to the hospital and every eight hours thereafter. Increase B.R.’s activity as he tolerates it during his hospital stay.Consult physical and occupational therapy upon admission to the hospital. Use correct assistive devices during ambulation and transfers while in the hospital. Assess knowledge and correct use of these assistive devices by B.R. and his wife during admission so that they can be used appropriately after discharge. Conference physician about medications and their risks/ benefits to B.R. upon admission to the hospital. Use appropriate fall risk identifiers and protocols to lessen the risk of injury while in the hospital. Educate B.R. and his wife about medications purpose and side effects upon admission to hospital. Involve pharmacist if additional education is required. Assess the home for modifiable adaptions to keep the home free of harm prior to discharge to maintain B.R.’s independence and safety (Alzheimer’s Society, 2015). Caregiver role strain related to unrelenting or complex care requirements secondary to chronic mental illness as evidenced by increased agitation and violent outbursts exhibited by the patient. Support and encourage active listening with B.R.’s wife to verbalize her feelings about her caregiving efforts and strains. Consult a counselor and support group upon admission to the hospital and have resources available after discharge.Have discharge planner gather resources on Commission of Aging. The Commission on Aging will “provide services and programs that support older adults” in the community (Grand Traverse County, 2006). Have discharge planner gather resources on Family Health Center so that affordable healthcare and support groups can be utilized upon discharge (Baldwin Family Health Care, 2015). Discuss with B.R.’s wife when to seek help if B.R. becomes violent and agitated again upon discharge. EvaluationWith a multiple day hospital acute care admission, change of medications and support services in line, B.R.’s behavior and affect should improve prior to discharge. Additional resources and continued counselling post discharge will help to maintain B.R.’s mood and affect and help to prevent readmission. However, if this behavior continues and multiple readmissions occur, an admission to a Skilled Nursing Facility for rehabilitation would be wise. Counselling on medications, work with physical and occupational therapy and working to make B.R. stronger and more independent by discharge with continued work after discharge will help to decrease B.R.’s fall risk. The wife will be educated on proper transport of the patient, however with the resources available while admitted to the hospital, B.R. will become stronger and carry a steadier gait prior to discharge. With communication and proper counselling referrals, B.R.’s wife will have the support she needs in place prior to discharge to be able to continue to care for B.R. She will also have a respite from caring for B.R. while he is admitted to the hospital. With the care for B.R. being focused on improving his mood, behavior and affect and also decreasing his risk for falls, caring for B.R. will become easier prior to discharge for B.R.’s wife. Follow up appointments and home care will be made and set up prior to discharge with B.R.’s physician and all specialties including: laboratory services, counselling, physical therapy and support groups. This will help to ensure the safety of B.R. and his wife and to guarantee that B.R. is progressing medically. PolicyThere are many policy implications associated with Alzheimer’s dementia. Alzheimer’s Society (2015) campaigns to raise awareness of Alzheimer’s to the general public, with health professionals and with policy makers. Many countries are working on and funding research on how to prevent and/or cure Alzheimer’s dementia. According to the U.S. Department of Health and Human Services (n.d.) they are the leading funder of Alzheimer’s research, “the federal government is supporting significant new research into the causes of Alzheimer’s and finding ways to delay, prevent, or treat the disease.” There also continues to be a need for additional resources for geriatric patients. Often times, there are not enough beds available for Skilled Nursing Facility admissions. There are clearly not enough places for people that are violent and agitated to go for help and care. Hospitals often take the brunt of caring for violent and agitated patients while they are medically stable to be discharged, but there is no viable discharge plan available. This can then can cause caregiver strain on nursing staff. This also is not ideal for the rest of the patients who are seeking care in the hospital for reasons unrelated to this; they may be recovering from surgery or have other chronic disorders and they have a hard time getting the rest they need because of the behavior of other patients. There are also always waiting lists for the Commission on Aging, which provides a great service so that the elderly can continue to be independent. There just really is not enough resources available to care for this growing population. ConclusionB.R. was admitted to the hospital for “not being himself” as stated by the wife, he was increasingly agitated at home along with having a weak and unsteady gait. With the help of additional medications and many support services such as good nursing care, specialty referrals, physical and occupational therapy and proper discharge planning B.R. will be able to return home with his wife. His behavior and affect have improved, his strength has improved and B.R.’s wife was able to get some support and a relief of his care during his hospital stay. The diagnoses that were made based on B.R.’s assessment have been intervened upon and they will continue to improve based on all of the resources and support B.R. and his wife will have after discharge. The wife was counselled on activities in the community they could share together to increase B.R.’s hope for the future and so that he can remain an active member of his community which will increase his chances of aging successfully. All of this care and these resources will continue to improve his mood while still his Alzheimer’s dementia is still being managed and allow him to stay independent and at home for as long as he and his wife are able to be safe and free of harm. ReferencesAlzheimer’s Society. (2015). Remaining independent. Retrieved from Family Health Care. (2015). Family health care. Retrieved from Carpenito-Moyet, L.J. (2008). Handbook of nursing diagnosis. (12th ed.). Philadelphia, PA: Wolters Kluwer/ Lippincott Williams & Wilkins. Grand Traverse County. (2006). Commission on aging. Retrieved from , E. (n.d.). Depression in patient with dementia. Retrieved from Paws. (n.d.). Heinrich II fall risk assessment. Retrieved from Practicing Physician Education in Geriatrics. (n.d.). Depression tool kit. Retrieved from , T.A. & Jett, K. (2012). Ebersole & Hess’ toward healthy aging: Human needs & nursing response. (8th ed.). St. Louis, MO: Elsevier. U.S. Department of Health and Human Services. (n.d.). Fighting Alzheimer’s. Retrieved from Walla Community College. (n.d.). Braden scale for predicting pressure sore risk. Retrieved from ABRADEN SCALE FOR PREDICTING PRESSURE SORE RISK1 Point2 Points3 Points4 PointsSensory PerceptionAbility to respond meaningfully to pressure-related discomfortCompletely limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli because of diminished level of consciousness or sedation. ORLimited ability to feel pain over most of body surface.Very limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.ORHas a sensory impairment that limits the ability to feel pain or discomfort over half of body.Slightly limited: Responds to verbal commands but cannot always communicate discomfort or need to be turned.ORHas some sensory impairment, which limits ability to feel pain or discomfort in 1 or 2 extremities.No impairment: Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort.MoistureDegree to which skin is exposed to moistureConstantly moist: Skin is kept moist almost constantly by perspiration, urine, etc. Damp-ness is detected every time patient is moved or turned. Very moist: Skin is often, but not always, moist. Linen must be changed at least once a shift.Occasionally moist:Skin is occasionally moist, requiring an extra linen change approximately once a day.Rarely moist:Skin is usually dry; linen requires changing only at routine intervals.ActivityDegree of physical activityBedfast: Confined to bed.Chairfast:Ability to walk severely limited or nonexistent. Cannot bear own weight and / or must be assisted into chair or wheelchair.Walks occasionally:Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.Walks frequently:Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.MobilityAbility to change and control body positionCompletely immobile: Does not make even slight changes in body or extremity position without assistance.Very limited:Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.Slightly limited:Makes frequent though slight changes in body or extremity position independently.No limitations:Makes major and frequent changes in position without assistance.NutritionUsual food intake patternVery poor: Never eats a complete meal. Rarely eats more than one third of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement.ORIs NPO and / or maintained on clear liquids or IVs for more than 5 days.Probably inadequate: Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement.ORReceives less than optimal amount of liquid diet or tube feeding.Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered.ORIs on a tube-feeding or TPN regimen that probably meets most of nutritional needs.Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplements.Friction and ShearProblem: Requires moderate to maximal assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximal assistance. Spasticity, contractions, or agitation leads to almost constant friction.Potential problem: Moves feebly or requires minimal assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.No apparent problem: Moves in bed and in chair independently and has sufficient muscle strength to sit up completely during move. Maintains good position in bed or chair at all times.Score: 20Instructions: Score client in each of the six subscales. Maximum score is 23, indicating little or no risk. A score of < 16 indicates “at risk”, a score <9 indicates high risk.(Pillow Paws, n.d.)Appendix BHendrich II falls Risk ModelComplete 8 hour shift, changed condition, or transferConfusion/Disorientation/Impulsiveness444Depression (Nursing staff assesses patient or patient states “depressed”)222Altered Elimination (leakage of urine or stool, “can’t wait” or gets up 4 or more times/night)111Dizziness/Vertigo (reported by patient)111Gender (Male)111Any antiepileptics Carbamazepine (Tegretol, Carbatrol), divalproex (Depakote), fosphenytoin (Cerebryx injection) gabapentin (Neurontin), lamotrigine (Lamictal), levetiracetam (Keppra), mephobarbital, (Mebaral) oxcarbazepine (Trileptal), Phenobarbital, (phenytoin), (Dilantin), topiramate (Topamax) and valproic acid (Depakene)222Any benzodiazepines: (Alprazolam (Xanax), chlordiazepoxide (Librium, Librax) clonazepam (Klonopin), diazepam (Valium), flurazepam (Dalmane), lorazepam (Ativan), midazolam (Versed), temazepam (Restoril), and triazolam (Halcion)111Get-Up-And-Go Test (Choose One):Rises in a single movement000Pushes up in one attempt111Multiple Attempts, successful333Unable to rise without assist444ADD TOTAL POINTS (>5 points = High Risk):11Check box if patient is on Fall Prevention Pathway See Pathway See Pathway See PathwayGet-Up-And-Go Test: Instructions: With patient sitting in a chair (preferred location) or on the side of the bed, place hands in lap and ask the patient to stand. Score of 0: Patient is able to stand and begin stepping in a single movement using only his/her legs. Score of 1: The patient can rise and begin stepping in a single attempt if utilizes his/her arms or a walker to push up. Score of 3: Patient requires more than one attempt to stand with or without use of hands, arms and walker. Score of 4: Patient cannot stand without assistance.(Walla Walla Community College, n.d.)Appendix CGeriatric Depression Scale (GDS)Instructions:Circle the answer that best describes how you felt over the past week.1.Are you basically satisfied with your life?yesno2.Have you dropped many of your activities and interests?yesno3.Do you feel that your life is empty?yesno4.Do you often get bored?yesno5.Are you in good spirits most of the time?yesno6.Are you afraid that something bad is going to happen to you?yesno7.Do you feel happy most of the time?yesno8.Do you often feel helpless?yesno9.Do you prefer to stay at home, rather than going outand doing things?yesno10.Do you feel that you have more problems with memory than most?yesno11.Do you think it is wonderful to be alive now?yesno12.Do you feel worthless the way you are now?yesno13.Do you feel full of energy?yesno14.Do you feel that your situation is hopeless?yesno15.Do you think that most people are better off thanyou are?yesnoTotal Score 12(Practicing Physician Education in Geriatrics, n.d.) ................
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