Module 4 Management of Chronic Health Problems in Older Adults Student Learning Outcomes List the essential components of a comprehensive health assessment of an older adult Describe medication use and common drug related problems in older adults Describe factors that can contribute to unsafe medication management at home Review the nurse s role in the older adult s adherence to a medication regimen Identify key laboratory values that increase or decrease with aging Describe the nurse s role in interpreting laboratory values for older adults Discuss the information that older adults should know about the use of select herbs and supplements Describe the issue of aging in rural America and its impact on managing older adult healthcare Assessment of an Older Adult RNs bring special abilities to the OA Listen patiently Allow for pauses Ask questions that are not often asked Observe for minute details Obtain data from all available sources Obtain collateral information Recognize normal changes associated with late life Health Assessment for OA More time related to increased number of chronic illness and social complexities of living longer Quality speed of the assessment are an art born of experience Benner 1984 says a task for an expert Assessment Results Snapshot of health status at that moment Information critical to development of plan of care that can enhance personal health status Decrease chronic conditions potential for or severity of Encourage self efficacy Improvement of self care Health History Beginning of nurse older adult relationship Functional status self report or proxyreport Social history Diverse population Recommend the use of the culturally sensitive Explanatory Model see p 108 Box 7 1 Psychological assessment cognitive emotional Caregiver health Home safety Physical Assessment The Try This series Evidenced Based Protocols SPICES FANCAPES FANCAPES F fluids A aeration N nutrition C communication Literacy A activity P pain E elimination S social skills SPICES 6 common geriatric disorders Using Fulmer s SPICES S sleep disorders P problems with eating feeding I incontinence C confusion E evidence of falls S skin breakdown Fulmer s SPICES Framework In Older Adults addresses Normal aging changes Increased risk of health related problems Prevalent community occurring problems Helps nurse prevent iatrogenesis promote optimal function Flagging conditions allows nurse to implement preventative therapeutic interventions Provides a snapshot of older adult s overall health Using SPICES Used to complement more detailed assessments Fulmer 2007 responses noted in record more detailed assessment performed the creation of interventional strategies noted in plan of care Complete on day of admission on each day of hospitalization for those 65 years Functional Assessment Objective measures v self report or proxy Self report is over estimated Proxy is under estimated ADLs Katz Index bathing dressing toileting transferring continence feeding Discuss Katz ADL video Functional Independence Measure IADLs Tasks needed for independent living Cleaning yard work shopping money management Cognitive physical function higher needs than for ADLs Some Tests Timed Get Up and Go Test 10 sec 20 secs The Blessed Dementia Scale Clinical Dementia Rating Global Deterioration Scale Functional Independent Measure FIM rehab Mini Mental State Examination MMSE Mini Cog Clock Drawing Test Geriatric Depression Scale Katz IADLs video Minimum Data Set MDS CMS MDS 3 0 Comprehensive assessment used in LTC Plan Monitor Describe care Includes now EB measures of pain cognition delirium depression Accurate clinically relevant efficient improved detection of clinical problems RUGS determine reimbursement Resource Utilization Group Key Concepts Assessment of physical cognitive psychological environmental status is essential in meeting the specific needs of the older adult and implementing appropriate interventions Knowledge of how to use a particular gerontological assessment tool is needed to accurately administer it Gives you an objective tool for reassessment at a later date Comorbidity of many older adults complicates obtaining and interpreting Laboratory Values Diagnostics Knowledge related to lab values diagnostic tests In Older Adults more difficult to interpret In LTC especially important to monitor ensure prompt treatment APRNs RBC Count Change is in speed at which produced in late life decreased Decreases bone marrow reserves Decreased renal Fx erythropoetin Recovery from blood loss takes longer Increases risk of falls delirium etc 6x increase in anemia 8 22 Hemoglobin Hematocrit Each gram of hemoglobin Hgb carries 1 39mL of oxygen Hemoglobin or 5g dL and 20 critical value Why is an elevated Hgb a concern Accurate result Hypervolemia Anemia in the OA The only age group in which Anemia of Chronic Disease is the 1 type of Anemia VB12 deficiency Normocytic normochromic Iron Deficiency Anemia is 1 in all other age groups Microcytic CBC indices Men anemia is Hgb 13 Women anemia is Hgb 12 MCV MCH RDW WBC Count Live 13 20 days 5000 10 000 WBCs mm3 2500 or 30 000 critical values Bacteremia typical signs symptoms absent in OA What you will see is the left shit increased immature neutrophils bands WBC differential Granulocytes Neutrophils Basophils Eosinophils Agranulocytes Monocytes Lymphocytes Cont The Older Adult has a delayed response to intrusion of foreign substances The Immunity Theory of Aging Wait for typical S S of bacteremia OA may well die New onset or increased confusion delirium Falling Incontinence A Change in ability to function daily Platelets Thrombocytes Sticky plug at site of injury to stop bleeding 150 000 400 000 mm3 is normal Cont Thrombocytopenia Platelets 100 000 mm Thrombocythemia Platelets 1 million mm Key Laboratory Values in Older Adults The older the person is the more difficult is the interpretation of lab findings the more important your skills We must take the knowledge of normal changes and consider the person in terms of his or her unique health status and needs Nurses Interpreting Lab Values Erythrocyte sedimentation rate ESR or sed rate C reactive protein AMI Iron studies Transferrin protein that transport iron Ferritin protein TIBC B vitamins Folic acid Vitamin B12 Elevated MCV macrocytic anemias PT PTT INR Cont DEHYDRATION is most common cause of electrolyte imbalance in the Older Adult Electrolytes K Hyperkalemia 5 Hypokalemia 3 5 Na confusion seizures Calcium phosphorus seesaw