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Chapter 14: Management of Common Problems


Chapter 14: Management of Common Problems Bonnie M. Wivell, MS, RN, CNS Polypharmacy Demographics 34% of all prescription medications and 40% of all nonprescription ... – PowerPoint PPT presentation

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Title: Chapter 14: Management of Common Problems

Chapter 14 Management of Common Problems
  • Bonnie M. Wivell, MS, RN, CNS

  • Demographics
  • 34 of all prescription medications and 40 of
    all nonprescription medications are for elderly
    (American Society of Consultant Pharmacists,
  • Those in nursing homes take an average of 6 8
    medications per day some take many more

Polypharmacy (contd)
  • Concurrent use of several drugs (ANA)
  • Implications
  • Med errors
  • Non-adherence
  • Drug-drug interactions
  • ADRs
  • Increased hospitalizations
  • Risk Factors for polypharmacy
  • Poor communication between physicians, number of
    co-morbidities, age-related change
  • Beers list of potentially harmful drugs

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  • Obtain a thorough history
  • Start low and go slow
  • Monitor lab values
  • Consider nonpharmacologic approaches
  • Streamline the medication regimen
  • Provide information to patient/family

  • Demographics
  • In 2001, more than 1.6 million seniors were
    treated in emergency departments for fall-related
    injuries and nearly 388,000 were hospitalized
  • Implications
  • Fractures
  • Loss of independence
  • Decreased quality of life
  • Fear
  • Death
  • At least 50 of elderly persons who were
    ambulatory before fracturing a hip do not recover
    their pre-fracture level of mobility

Falls (contd)
  • Risk for falling
  • Intrinsic r/t changes associated with aging
  • Extrinsic r/t environmental hazards
  • Drugs are a major contributing factor
  • Fall assessment
  • Initial
  • Regular intervals
  • Variety of assessment tools available

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Risk Factors for Falls
  • Age
  • Diagnosis
  • Altered physical capabilities
  • Altered mental state
  • Altered bowel and bladder function
  • Cognitive/sensory impairments
  • Altered proprioception
  • Day of hospitalization
  • Medications
  • Psychological factors, i.e. fear

Interventions/Strategies for Care
  • Evaluate gait and balance
  • Up and Go Test
  • Exercise
  • Restraint use
  • Avoid physical restraints
  • Limit use of chemical restraints effects
    number of certain medications that can be used in
    nursing homes

Interventions (contd)
  • Modify the environment
  • Minimize clutter
  • Throw rugs
  • Hand rails
  • Flooring wax, loose carpet, wires/cords
  • Be sure phone can be reached from floor
  • Raised toilet seat
  • Grab bars
  • Educate client and family

Interventions (contd)
  • Medication review
  • Diuretics
  • Narcotics
  • Sedatives
  • Hypnotics
  • Tranquilizers
  • Antidepressants
  • Antihypertensives
  • Laxatives
  • History of drug/alcohol abuse
  • Develop a Fall Prevention Plan
  • Examine risk factors

  • Prevalence
  • Most common mental health problem in older adults
  • According to Surgeon General, 11.4 of adults
    over the age of 55 met criteria for anxiety
  • Phobic anxiety disorders most prevalent in older
  • Non-specific anxiety rates up to 17 in older men
    and 21 in older women (U.S. Public Health
    Services, 2000).

  • Manifests as
  • Tachycardia/Palpitations
  • GI disorders
  • Insomnia
  • Tachypnea
  • Recurring and chronic can complicate illnesses
  • Increases duration of disability
  • Correlates with and predicts cognitive decline
    and impairment
  • Elevates acute pain perception

Warning Signs
  • Generalized anxiety disorder (GAD) persistent,
    excessive worry with fluctuating severity of
    symptoms, restlessness, irritability, sleep
    disturbance, fatigue and impaired concentration
  • Chronic condition
  • Associated with depression
  • Panic attacks autonomic arousal that includes
    tachycardia, difficulty breathing, diaphoresis,
    light-headedness, trembling, and severe weakness
  • Symptoms may be masked in elderly

Risk Factors/Assessment
  • Risk Factors
  • Chronic medical condition
  • Psychosocial stressors/negative life event
  • Catastrophic events in early life
  • Assessment
  • ID risks
  • Medications
  • Medical conditions
  • Pay attention to verbalization of thoughts and
  • Most prominent presenting symptom in depression

Intervention/Strategies for Care
  • Decrease environmental stimuli
  • Stay with the patient
  • Make no demands or ask the patient to make
  • Support current coping mechanisms (crying,
  • Avoid confrontation or argument
  • Speak slowly and softly
  • Reassure the patient that the problem can be
  • Reorient the patient to reality
  • Respect the patients personal space
  • Deep Breathing
  • Progressive Muscle Relaxation
  • Cognitive Behavioral therapy
  • Anxiolytics (benzos, SSRIs 1)

  • Most common mental health disorder in elderly but
    NOT a normal consequence of aging
  • Depression rate is as high as 37 in older adults
    with co-morbid illnesses
  • Medical conditions that increase risk of
  • Hypothyroidism, Arthritis, HTN, CVA, CHD, DM, PD,
    MS, CA
  • Significant risk for suicide older adults have
    the highest rates of suicide in the US
  • Often undetected or inadequately treated

  • Geriatric Depression Scale
  • Cornell Scale for Depression in Dementia
  • Medication history
  • H P

Interventions/Strategies for Care
  • Early recognition and tx can increase quantity
    and QOL
  • Antidepressant medications (tricyclics, SSRIs 1)
  • Psychosocial interventions
  • CBT uses recognition and relaxation strategies to
    change thoughts
  • Nursing interventions
  • Alternative medicine
  • Life review
  • Socialization
  • Exercise
  • Community resources

Urinary Incontinence (UI)
  • Involuntary leakage of urine
  • Is common problem but NOT a normal part of aging
  • Requires evaluation
  • Types of UI
  • Stress
  • Urge
  • Mixed
  • Overflow
  • Functional
  • Total

  • 30 - 50 in older women living in the community
  • 9 28 in older men living in the community
  • Incontinence may affect up to 43 of acute care
  • Prevalence rates in institutions rise to 50 or

  • Depression/anxiety
  • Decreased quality of life
  • Relationships
  • ADLs
  • Decreased socialization
  • Increased risk of hospitalization and/or
    admission to LTCF
  • Increased risk of falls
  • Increase risk of skin breakdown
  • Stigma
  • Fear of embarrassment
  • Perception that UI is a normal part of aging

  • Transient (acute)
  • Delirium, infection, meds, stool impaction
  • Established (chronic)
  • Stress, urge, overflow, functional
  • Evaluating bladder function
  • History
  • Bladder diary
  • Physical
  • DRE, pelvic exam
  • PVR
  • UA
  • Cognitive status
  • Environmental resources location, accessibility
    of toilet

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Stress Incontinence
  • Involuntary loss of small amounts of urine during
    activities that increase intra-abdominal pressure
  • Lifting, coughing, sneezing, laughing
  • Causes
  • Hypermobility of the bladder neck
  • Urethral sphincter defects
  • Weakness of pelvic floor muscles r/t pregnancy,
    multiparity, obesity, surgery, exercise,
  • Treatment biofeedback, Kegels

Urge Incontinence
  • Strong, abrupt desire to void and the inability
    to inhibit leakage in time to reach a toilet
  • Moderate to large amounts of urine lost
  • Causes
  • CNS disorders such as CVA, MS
  • Local irritations such as infection or ingestion
    of bladder irritants like caffeine
  • Treatment Kegels

Reflex Incontinence
  • A variation of urge, results from uninhibited
    bladder contractions with no sensation of needing
    to void or urgency
  • Large amount urine lost
  • Causes
  • Spinal lesions transecting above T10-11 r/t birth
    defects, spine or nerve damage, developmental
    disability, senility, pelvic trauma
  • Treatment determine cause may need intermittent
    cath, timed voiding

Overflow Incontinence
  • Over-distention of the bladder due to abnormal
  • Causes
  • Weak bladder
  • Neurological conditions like DM, spinal cord
    injury below T10-11
  • Bladder outlet obstruction
  • No warning prior to incontinent episode
  • Small to moderate amount of urine lost
  • Continual or intermittent
  • Treatment treat cause, intermittent cath,
    bladder scans for post-void residuals

Functional Incontinence
  • Problems with factors external to the lower
    urinary tract such as cognitive impairment,
    physical disabilities, and environmental barriers
  • Related to inability to get to bathroom
    facilities due to functional reasons
  • For example obesity, clutter, immobility
  • May be associated with urge incontinence (mixed
  • Treatment modify environment modify lifestyle

Mixed Incontinence
  • Existence of symptoms of urge and stress at the
    same time

Interventions/Strategies for Care
  • Behavioral Management modify behavior or
  • Scheduling regimens
  • Relaxation exercises
  • Pelvic muscle exercises
  • Urge suppression techniques with or without
  • Biofeedback, Vaginal cones, Electrical stim
  • Hydration management
  • Bowel regularity
  • Prompted voiding
  • Bladder training

Interventions/Strategies for Care
  • Pharmacological management
  • Medications that alter detrusor muscle activity
    or bladder outlet resistance
  • Surgery
  • Increase bladder outlet resistance
  • Remove bladder outlet obstruction
  • Devices and products
  • Depends, catheter supplies, urinals

Sleep Disorders
  • Sleep Changes Associated with Aging
  • Decreased deep stage IV (restores the individual
    physically, and tissue healing occurs)
  • Decreased REM sleep (deepest state of relaxation)
  • Prevalence
  • Chronic illness increases propensity
  • 32 of adults reported a good nights sleep only
    a few nights each month

Types of Sleep Disturbances
  • Insomnia
  • Sleep apnea
  • Restless leg syndrome

Interventions/Strategies for Care
  • Sleep hygiene
  • Environmental restructuring
  • Relaxation
  • Aromatherapy
  • Herbal therapy
  • Medications
  • Ambien
  • Lunesta
  • Sonata

Pressure Ulcers
  • Prevalence
  • Acute care setting 3-11
  • Long-term care facilities 24
  • Community 17
  • With a stage I ulcer, the older adult has a
    tenfold risk of developing further ulcers
  • Implications
  • Ischemia caused by unrelieved pressure

Warning Signs/Risk Factors
  • Thin or obese
  • Poor nutrition/dehydration
  • Immobility
  • Assistive devices
  • Patient on pain meds or sedatives
  • Decreased mental status
  • Increased age
  • Impaired circulation/sensation
  • Bony prominences/decreased muscle mass
  • Incontinence
  • Friction/shearing

  • Braden Scale
  • See pages 502-503 in text
  • Score of 18 or less high risk of pressure ulcer
    development in the older adult
  • Determine baseline on admission and at regular
  • Determine stage
  • Length, width, and depth need to be documented
  • Photos

Stages of Pressure Ulcers
  • Stage I non-blanchable redness, skin intact
  • Stage II partial thickness loss of the dermis,
    abrasion, blister, shallow crater
  • Stage III full-thickness loss of dermis, damage
    to subcutaneous tissue
  • Stage IV damage to muscle and bone, necrosis

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Ulcer Care
  • Cleanse the wound with a noncytotoxic cleanser
    (saline) during each dressing change.
  • If necrotic tissue or slough is present, consider
    the use of high-pressure irrigation.
  • Debride necrotic tissue.
  • Do not debride dry, black eschar on heels.
  • Perform wound care using topical dressings
    determined by wound and availability.
  • Choose dressings that provide a moist wound
    environment, keep the skin surrounding the ulcer
    dry, control exudates, and eliminate dead space.

Ulcer Care (contd)
  • Reassess the wound with each dressing change to
    determine whether treatment plan modifications
    are needed.
  • Identify and manage wound infections.
  • Clients with Stage III and IV ulcers that do not
    respond to conservative therapy may require
    surgical intervention.

Pressure Ulcer Management
  • Nutrition very important
  • Protein
  • Zinc
  • Arginine
  • Vit C, A, and B
  • Tissue load management
  • Positioning devices
  • PUSH Tool

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  • Problems with swallowing that is an
    under-recognized, poorly diagnosed, and poorly
    managed health problem
  • Negatively impacts quantity and QOL
  • Prevalence
  • 13-35 of elderly living in the community
  • 25-30 of hospitalized patients
  • Approximately 30-40 of persons in nursing homes
  • It is estimated that by 2010, 16.5 million
    persons will require care for dysphagia (U.S.
    Census Bureau, 2000).

Warning Signs/Risk Factors
Effects of Aging on Eating and Swallowing
  • Impaired mastication - dentures
  • Change in diet, change in appetite
  • Diminished salivary secretions
  • Decreased esophageal peristalsis
  • Decreased production of digestive enzymes

  • Stages of swallowing
  • Oral preparatory chew and taste
  • Oral or lingual move food to back of throat
  • Pharyngeal involuntary, most critical, airway
  • Esophageal involuntary, movement down esophagus
    via peristalsis

Assessment (contd)
  • Cranial nerves involved in eating and swallowing
  • Trigeminal (V) - mandibular, maxillary
  • Facial (VII) - taste, submandibular and
    sublingual salivary glands, facial expression
  • Glossopharyngeal (IX) - taste, soft palate
  • Vagus (X) - membrane of larynx and pharynx
  • Spinal Accessory (XI) - sternocleidomastoid
  • Hypoglossal (XII) - intrinsic tongue

Interventions/Strategies for Care
  • Positioning - upright
  • Establish arousal and attention
  • Assist with head positioning
  • Do not rush
  • Use small amounts of food - 1/2 teaspoons
  • Place food on unaffected side
  • Push down tongue as remove food from spoon

Interventions (contd)
  • Assist with lip closure if needed
  • Avoid use of straws (unless recommended by speech
  • Provide frequent verbal cues
  • Use thickener for liquids as recommended
  • Stimulate the swallowing reflex
  • Avoid milk and milk products
  • Use adaptive equipment designed for that person

Interventions (contd)
  • Oral care
  • Educate person and family
  • Thermal stimulation - cold stimulates the swallow
  • Follow recommendations of speech therapist (may
    have multiple steps)

Non-oral interventions
  • G-tubes
  • PEG tubes
  • Percutaneous Endoscopic Gastrostomy tube
  • Check abdominal girth for distension
  • Check residual volumes
  • Keep upright after feedings
  • Monitor continually for aspiration
  • Treat GERD

Chapter 15 Nursing Management of Dementia
  • Bonnie M. Wivell, MS, RN, CNS

  • Progressive, degenerative brain dysfunction,
    including deterioration in memory, concentration,
    language skills, visuospatial skills, and
  • Progressive forgetfulness, memory loss, and loss
    of other cognitive function
  • Increased plaques and tangles in the brain
    (hallmark sign for Alzheimers)
  • Interferes with a persons daily functioning
  • Not considered a normal part of aging

Types of Dementia
  • Alzheimers 1
  • Vascular
  • Parkinsons
  • Lewy body
  • Frontal lobe dementia
  • Lose inhibition and executive functioning skills
    earlier than AD
  • Normal pressure hydrocephalus
  • Rare but partially reversible with surgery
  • Acute onset of a triad of symptoms
  • slowed cognitive processes, gait disturbances, UI

Risk Factors for Dementia
  • Age
  • Family history
  • Genetic factors
  • Head trauma
  • Vascular disease
  • Infections
  • Other modifiable factors
  • Maintain ideal body weight
  • Exercise
  • Avoid smoking
  • Control hyperlipidemia and hypertension
  • Exercising the brain with lifelong cognitive
    activity may help lower the risk of dementia

Causes of Dementia
  • Drugs
  • Environmental
  • Metabolic
  • Eyes/Ears sensory deprivation
  • Nutrition
  • Trauma/Tumor
  • Infections
  • Alcohol abuse or intoxication

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Assessing for Dementia
  • Mini-COG
  • A reliable and valid instrument used to screen
    for cognitive impairment consisting of 3-item
    recall test and a clock-drawing test (CDT)
  • It is evidence-based, easy to administer, and not
    too taxing for patient or provider
  • Is a screening test, doesnt provide diagnosis

Administration of Mini-COG
  • Instruct the patient to listen carefully to and
    remember 3 unrelated words and then to repeat the
  • Instruct the patient to draw the face of a clock,
    either on a blank sheet of paper, or on a sheet
    with the clock circle already drawn on the page.
    After the patient puts the numbers on the clock
    face, ask him or her to draw the hands of the
    clock to read a specific time, such as 1120.
    These instructions can be repeated, but no
    additional instructions should be given. Give the
    patient as much time as needed to complete the
    task. The CDT serves as the recall distracter.
  • Ask the patient to repeat the 3 previously
    presented word.

Scoring of Mini-COG
  • Give 1 point for each recalled word after the CDT
    distracter. Score 13.
  • A score of O indicates positive screen for
  • A score of 1 or 2 with an abnormal CDT indicates
    positive screen for dementia.
  • A score of 1 or 2 with a normal CDT indicates
    negative screen for dementia.
  • A score of 3 indicates negative screen for
  • The CDT is considered normal if all numbers are
    present in the correct sequence and position, and
    the hands readably display the requested time.

Diagnosing Alzheimers
  • Memory impairment alone doesnt indicate AD
  • Requires one of the following features
  • Impaired executive function
  • Aphasia word finding difficulties
  • Apraxia cannot carry out motor skills
  • Agnosia cannot name familiar object
  • Must rule out delirium, depression, other CNS
    disorders, medication side effects, and other
    medical conditions first!

Diagnosing Alzheimers (contd)
  • H P
  • Review of medications
  • Laboratory testing
  • Neuropsychological screening/testing
  • Mini Mental Status Exam (MMSE) no longer
    available in public domain
  • Mini-Cog
  • St. Louis University Mental Status (SLUMS) exam
  • Imaging
  • Medicare will pay for PET scan to rule out

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Medications for Dementia
  • Medications slow progression but do not stop
    decline over time
  • Cholinesterase Inhibitors (CEIs)
  • donepezil (Aricept)
  • rivastigmine (Exelon)
  • galantamine (Razadyne)
  • N-methyl-D-aspartate (NMDA) Receptor Antagonist
  • memantine (Namenda) approved for moderate to late
  • Anticholinergics can worsen cognitive function
  • See page 540 in text

  • Acute confusion
  • Four basic features
  • Acute onset or fluctuating course
  • Inattention
  • Disorganized thinking
  • Altered level of consciousness
  • Primary treatment is to eliminate the cause
  • Delusion of theft and phantom intruder

Another Fact About Dementia
  • Study done in Japan Delusion of theft and
    phantom intruder delusion are among the most
    frequent delusions in dementia and these
    delusions occur more frequently when pt.

Causes of Delirium
  • Drugs
  • Electrolytes
  • Liver failure
  • Infection
  • Renal failure
  • Impaction
  • UTI or urinary retention
  • Metastasis

Potential Causes of Delirium
  • Inadequate or inappropriate pain control
  • Medications (including new or change in dose)
  • Fecal impaction
  • Infection/fever
  • Injury/severe illness
  • Electrolyte imbalance (glucose, Na)
  • Dehydration
  • Change in surroundings
  • Hypoxia
  • Age
  • Male gender
  • Cognitive impairment (dementia)
  • Hypotension
  • Malnutrition
  • Depression
  • Alcoholism
  • Restraints
  • Multiple IVs, lines, tubes

Assessing for Delirium
  • Delirium is often unrecognized by clinicians
  • Hence patients should be assessed frequently
    using a standardized tool to facilitate prompt
    identification and management of delirium and
    underlying etiology
  • Confusion Assessment Method (CAM)
  • Sensitivity of 94-100
  • Specificity of 89-95

CAM The Short Version
  • 1. Acute Onset
  • Is there evidence of an acute change in mental
    status from baseline?
  • 2. Inattention
  • Does the patient have difficulty focusing
    attention easily distractible have difficulty
    keeping track of what is being said?
  • Does this behavior fluctuate come and go or
    increase and decrease in severity?

  • 3. Disorganized thinking
  • Is the patients thinking disorganized or
    incoherent, such as rambling or irrelevant
    conversation, unclear or illogical flow of ideas,
    or unpredictable switching from subject to
  • 4. Altered level of consciousness
  • Overall, how would you rate this patients level
    of consciousness?
  • Alert normal
  • Vigilant hyper-alert, overly sensitive to
    environmental stimuli, startled very easily
  • Lethargic drowsy, easily aroused
  • Stupor difficult to arouse
  • Coma unarousable
  • Uncertain

CAM Continued
  • Should assess patient on admission and during
    each shift
  • Engage pt. in conversation for about one minute.
  • What brought you to the hospital?
  • How are you feeling now?
  • Delirium is identified only if there is evidence
    of features 1 and 2, and either 3 or 4 (or both)

  • Risk increases in older adults with chronic
    illnesses and/or dementia
  • Often a missed diagnosis
  • See Box 15 12 on page 541 of text for criteria
    of major depression
  • Most common screening tool is the GDS
  • The Cornell tool can be used to screen persons
    with dementia for depression
  • Symptoms of dementia, delirium, and depression
    often overlap

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Nursing Interventions/Strategies
  • Use general strategies (as appear in next slides)
  • Address specific issues/behaviors
  • Wandering
  • Aggression
  • Restlessness
  • Agitation
  • Physical comfort
  • Pain

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  • Clinical observations of facial expressions and
    vocalizations are accurate means for assessing
    the presence of pain, but not its intensity, in
    patients unable to communicate verbally because
    of advanced dementia.

  • Nonverbal Expressions
  • Agitation/combativeness/resistance to care
  • Increased confusion
  • Decreased mobility
  • Guarding/rubbing or holding particular body part
  • Grimacing
  • Restlessness
  • Increase HR, Respirations

Interventions for Pain
  • Ask older adults with dementia about their pain
    as they can often respond to simple questions
  • If pain is suspected, consider a time-limited
    trial of an appropriate type and dose of an
  • Nonpharmacological Interventions
  • Distraction
  • Massage
  • Heat/cold
  • Gentle movement/repositioning
  • Music therapy
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