Elective 2

Parameters of Assessment

ROCHELLE GEE C. OCASION

ELECTIVE 2

BSN 4-2

Submitted to: MAAM WILMA D. YMASA RN, MAN

EVIDENCED-BASED PRACTICE IN GERIATRIC NURSING

DEMENTIAParameters of Assessment

No formal recommendations for cognitive screening are indicated in asymptomatic individuals. Clinicians are advised to be alert for cognitive and functional decline in older adults to detect dementia and dementia-like presentation in early stages. Assessment domains include cognitive, functional, behavioral, physical, caregiver, and environment.A. Cognitive Parameters

1. Orientation: person, place, time

2. Memory: ability to register, retain, recall information

3. Attention: ability to attend and concentrate on stimuli

4. Thinking: ability to organize and communicate ideas

5. Language: ability to receive and express a message

6. Praxis: ability to direct and coordinate movements

7. Executive function: ability to abstract, plan, sequence, and use feedback to guide performanceB. Mental Status Screening Tools

1. Folstein Mini-Mental State Examination is the most commonly used test to assess serial cognitive change. On average, the MMSE declines 3 points per year in those with AD. The MMSE is copyrighted and a comparable tool called the St. Louis Medical Status (SLUMS) Examination is in the public domain.

2. Clock Drawing Test (CDT) is a useful measure of cognitive function that correlates with executive-control functions.C. Functional Assessment

1. Tests that assess functional limitations such as the Functional Activities Questionnaire (FAQ) can detect dementia. They are also useful in monitoring the progression of functional decline.

2. The severity of disease progression in dementia can be demonstrated by performance decline in activities of daily living (ADL) and instrumental activities of daily living (IADL) tasks and is closely correlated with mental-status scores.D. Behavioral Assessment

1. Assess and monitor for behavioral changes; in particular, the presence of agitation, aggression, anxiety, disinhibitions, delusions, and hallucinations.

2. Evaluate for depression because it commonly coexists in individuals with dementia. The Geriatric Depression Scale (GDS) is a good screening tool.E. Physical Assessment

1. A comprehensive physical examination with a focus on the neurological and cardiovascular system is indicated in individuals with dementia to identify the potential cause and/or the existence of a reversible form of cognitive impairment.

2. A thorough evaluation of all prescribed, over-the-counter, homeopathic, herbal, and nutritional products taken is done to determine the potential impact on cognitive status.

3. Laboratory tests are valuable in differentiating irreversible from reversible forms of dementia. Structural neuroimaging with noncontrast computed tomography (CT) or magnetic resonance imaging (MRI) scans are appropriate in the routine initial evaluation of patients with dementia.F. Caregiver/Environment

The caregiver of the patient with dementia often has as many needs as the patient with dementia; therefore, a detailed assessment of the caregiver and the caregiving environment is essential.

1. Elicit the caregiver perspective of patient function and the level of support provided.

2. Evaluate the impact that the patient's cognitive impairment and problem behaviors have on the caregiver (mastery, satisfaction, and burden). Two useful tools include the Zarit Burden Interview (ZBI) and the Caregiver Strain Index (CSI) Tool.

3. Evaluate the caregiver experience and patientcaregiver relationship.Nursing Care Strategies

The Progressively Lowered Stress Threshold (PLST) provides a framework for the nursing care of individuals with dementia.

A. Monitor the effectiveness and potential side effects of medications given to improve cognitive function or delay cognitive decline.

B. Provide appropriate cognitive enhancement techniques and social engagement.

C. Ensure adequate rests, sleep, fluid, nutrition, elimination, pain control, and comfort measures.

D. Avoid the use of physical and pharmacologic restraints.

E. Maximize functional capacity: maintain mobility and encourage independence as long as possible; provide graded assistance as needed with ADL and IADL; provide scheduled toileting and prompted voiding to reduce urinary incontinence; encourage an exercise routine that expends energy and promotes fatigue at bedtime; establish bedtime routine and rituals.

F. Address behavioral issues: identify environmental triggers, medical conditions, caregiverpatient conflict that may be causing the behavior; define the target symptom (i.e., agitation, aggression, wandering) and pharmacological (psychotropics) and nonpharmacological (manage affect, limit stimuli, respect space, distract, redirect) approaches, provide reassurance; and refer to appropriate mental health care professionals as indicated.

G. Ensure a therapeutic and safe environment: provide an environment that is modestly stimulating, avoiding overstimulation that can cause agitation and increase confusion, and under stimulation that can cause sensory deprivation and withdrawal. Utilize patient identifiers (name tags), medic alert systems and bracelets, locks, and wander guard. Eliminate any environmental hazards and modify the environment to enhance safety. Provide environmental cues or sensory aides that facilitate cognition, and maintain consistency in caregivers and approaches.

H. Encourage and support advance care planning: explain trajectory of progressive dementia, treatment options, and advance directives.

I. Provide appropriate end-of-life care in terminal phase: provide comfort measures including adequate pain management; weigh the benefits/risks of the use of aggressive treatment (e.g., tube feeding, antibiotic therapy).

J. Provide caregiver education and support: respect family systems/dynamics and avoid making judgments; encourage open dialogue, emphasize the patients residual strengths; provide access to experienced professionals; and teach caregivers the skills of caregiving.

Evaluation/Expected Outcomes

A. Patient Outcomes: The patient remains as independent and functional in the environment of choice for as long as possible, the comorbid conditions the patient may experience are well managed, and the distressing symptoms that may occur at end of life are minimized or controlled adequately.

B. Caregiver Outcomes (lay and professional): Caregivers demonstrate effective caregiving skills; verbalize satisfaction with caregiving; report minimal caregiver burden; are familiar with, have access to, and utilize available resources.

C. Institutional Outcomes: The institution reflects a safe and enabling environment for delivering care to individuals with progressive dementia; the quality improvement plan addresses high-risk problem-prone areas for individuals with dementia, such as falls and the use of restraints.

Follow-up to Monitor Condition

A. Follow-up appointments are regularly scheduled; frequency depends on the patients physical, mental, and emotional status and caregiver needs.

B. Determine the continued efficacy of pharmacological/nonpharmacological approaches to the care plan and modify as appropriate.

C. Identify and treat any underlying or contributing conditions.

D. Community resources for education and support are accessed and utilized by the patient and/or caregivers.MA. ISABEL C. MANALANG

ELECTIVE 2

BSN 4-2

MAAM WILMA D. YMASA RN, MAN

EVIDENCED-BASED PRACTICE IN GERIATRIC NURSING

-MEALTIME DIFFICULTIES-


A. Assessment of Older Adult and Caregivers

1. Rituals used before meals (e.g., handwashing and toilet use); dressing for dinner.

2. Blessings of food or grace, if appropriate.

3. Religious rites or prohibitions observed in preparation of food or before meal begins (e.g., Muslim, Jewish, and Seventh-Day Adventist; consult with pastoral counselor, if available).

4. Cultural or special cues: family history, especially rituals surrounding meals.

5. Preferences as to end-of-life decisions regarding withdrawal or administration of food and fluid in the face of incapacity, or request of designated health proxy; ethicist or social worker may facilitate process.

B. Assessment Instruments:

1. EdFED-Q for persons with moderate to late-stage dementia.

2. Katz Index of ADL for functional status.

3. Food diary/meal portion method.

Nursing Interventions

A. Environment

1. Dining or patient room: encourage older adult to eat in dining room to increase intake, personalize dining room, no treatments or other activities occurring during meals, no distractions.

2. Tableware: use of standard dinnerware (e.g., china, glasses, cup and saucer, flatware, tablecloth, napkin) versus disposable tableware and bibs.

3. Furniture: older adult seated in stable arm chair; table-appropriate height versus eating in wheelchair or in bed.

4. Noise level: environmental noise from music, caregivers, and television is minimal; personal conversation between patient and caregiver is encouraged.

5. Music: pleasant, preferred by patient.

6. Light: adequate and nonglare-producing versus dark, shadowy, or glaring.

7. Contrasting background/foreground: use contrasting background and foreground colors with minimal design to aid persons with decreased vision.

8. Odor: food prepared in area adjacent to or in dining area to stimulate appetite.

9. Adaptive equipment: available, appropriate, and clean; caregivers and/or older adult knowledgeable in use; occupational therapist assists in evaluation.

B. Caregiver/Staffing

1. Provide an adequate number of well-trained staff.

2. Deliver an individualized approach to meals including choice of food, tempo of assistance.

3. Position of caregiver relative to elder: eye contact; seating so caregiver faces elder patient in same plane.

4. Cueing: caregiver cues elder whenever possible with words or gestures.

5. Self-feeding: encouragement to self-feed with multiple methods versus assisted feeding to minimize time.

6. Mealtime rounds: interdisciplinary team to examine multifaceted process of meal service, environment, and individual preferences.

Evaluation/Expected OutcomesA. Individual

1. Corrective and supportive strategies reflected in plan of care.

2. Quality of life issues emphasized in maintaining social aspects of dining.

3. Culture, personal preferences, and end-of-life decisions regarding nutrition respected.B. Health Care Provider

1. System disruptions at mealtimes minimized.

2. Family and staff informed and educated to patient's special needs to promote safe and effective meals.

3. Maintenance of normal meals and adequate intake for the patient reflected in care plan.

4. Competence in diet assessment; knowledge of and sensitivity to cultural norms and preferences for mealtimes reflected in care plan.C. Institution

1. Documentation of nutritional status and eating and feeding behavior meets expected standard.

2. Alterations in nutritional status, eating and feeding behaviors assessed and addressed in a timely manner.

3. Involvement of interdisciplinary team (geriatrician, advanced practice nurse [NP/CNS], dietitian, speech therapist, dentist, occupational therapist, social worker, pastoral counselor, ethicist) appropriate and timely.

4. Nutritional, eating, and/or feeding problems modified to respect individual preferences and cultural norms.

5. Adequate number of well-trained staff who are committed to delivering knowledgeable and individualized care.

Follow-up Monitoring

A. Providers' competency to monitor eating and feeding behaviors.

B. Documentation of eating and feeding behaviors.

C. Documentation of care strategies and follow-up of alterations in nutritional status and eating and feeding behaviors.

D. Documentation of staffing and staff education; availability of supportive interdisciplinary team.

MICOLLE ERIKA F. JAVATE

ELECTIVE 2

BSN 4-2

Prof: Maam Wilma D. YmasaEVIDENCED-BASED PRACTICE IN GERIATRIC NURSING

DEPRESSION

Assessment Parameters

A. Identify risk factors/high risk groups

1. Current alcohol /substance-use disorder

2. Specific comorbid conditions: dementia, stroke, cancer, arthritis, hip fracture, myocardial infarction, chronic obstructive pulmonary disease, and Parkinsons disease

3. Functional disability (especially new functional loss)

4. Widow/widowers

5. Caregivers

6. Social isolation/absence of social support

7. Diminished perception of light in one's environment

B. Assess all at-risk groups using a standardized depression screening tool and documentation score. The GDS-SF is recommended because it takes approximately 5 minutes to administer, has been validated and extensively used with medically ill older adults, and includes few somatic items that may be confounded with physical illness.

C. Perform a focused depression assessment on all at-risk groups and document results. Note the number of symptoms; onset; frequency/patterns; duration (especially 2 weeks); change from normal mood, behavior, and functioning

1. Depressive symptoms

2. Depressed or irritable mood, frequent crying

3. Loss of interest, pleasure (in family, friends, hobbies, sex)

4. Weight loss or gain (especially loss)

5. Sleep disturbance (especially insomnia)

6. Fatigue/loss of energy

7. Psychomotor slowing/agitation

8. Diminished concentration

9. Feelings of worthlessness/guilt

10. Suicidal thoughts or attempts, hopelessness

11. Psychosis (i.e., delusional/paranoid thoughts, hallucinations)

12. History of depression, current substance abuse (especially alcohol), previous coping style

13. Recent losses or crises (e.g., death of spouse, friend, pet; retirement; anniversary dates; move to another residence, nursing home); change in physical health status, relationships, roles

D. Obtain/review medical history and physical/neurological examination.

E. Assess for depressogenic medications (e.g., steroids, narcotics, sedative/hypnotics, benzodiazepines, antihypertensives, H2 antagonists, beta-blockers, antipsychotics, immunosuppressives, cytotoxic agents).

F. Assess for related systematic and metabolic processes (e.g., infection, anemia, hypothyroidism or hyperthyroidism, hyponatremia, hypercalcemia, hypoglycemia, congestive heart failure, kidney failure).

G. Assess for cognitive dysfunction.

H. Assess level of functional ability.Care Parameters

A. For severe depression (GDS score 11 or greater, five to nine depressive symptoms [must include depressed mood or loss of pleasure] plus other positive responses on individualized assessment [especially suicidal thoughts or psychosis and comorbid substance abuse]), refer for psychiatric evaluation. Treatment options may include medication or cognitive behavioral, interpersonal, or brief psychodynamic psychotherapy/counseling (individual, group, family); hospitalization; or electroconvulsive therapy.

B. For less severe depression (GDS score 6 or greater, less than five depressive symptoms plus other positive responses on individualized assessment), refer to mental health services for psychotherapy/counseling (see previous types), especially for specific issues identified in individualized assessment and to determine whether medication therapy may be warranted. Consider resources such as psychiatric liaison nurses, geropsychiatric advanced practice nurses, social workers, psychologists, and other community- and institution-specific mental health services. If suicidal thoughts, psychosis, or comorbid substance abuse are present, a referral for a comprehensive psychiatric evaluation should always be made.

C. For all levels of depression, develop an individualized plan integrating the following nursing interventions:

1. Institute safety precautions for suicide risk as per institutional policy (in outpatient settings, ensure continuous surveillance of the patient while obtaining an emergency psychiatric evaluation and disposition).

2. Remove or control etiologic agents:

a. Avoid/remove/change depressogenic medications.

b. Correct/treat metabolic/systemic disturbances.

3. Monitor and promote nutrition, elimination, sleep/rest patterns, physical comfort (especially pain control).

4. Enhance physical function (i.e., structure regular exercise/activity; refer to physical, occupational, recreational therapies); develop a daily activity schedule.

5. Enhance social support (i.e., identify/mobilize a support person(s) [e.g., family, confidant, friends, hospital resources, support groups, patient visitors]); ascertain need for spiritual support and contact appropriate clergy.

6. Maximize autonomy/personal control/self-efficacy (e.g., include patient in active participation in making daily schedules, short-term goals).

7. Identify and reinforce strengths and capabilities.

8. Structure and encourage daily participation in relaxation therapies, pleasant activities (conduct a pleasant activity inventory), music therapy.

9. Monitor and document response to medication and other therapies; readminister depression screening tool.

10. Provide practical assistance; assist with problem solving.

11. Provide emotional support (i.e., empathic, supportive listening, encourage expression of feelings, hope instillation), support adaptive coping, encourage pleasant reminiscences.

12. Provide information about the physical illness and treatment(s) and about depression (i.e., that depression is common, treatable, and not the person's fault).

13. Educate about the importance of adherence to prescribed treatment regimen for depression (especially medication) to prevent recurrence; educate about specific antidepressant side effects due to personal inadequacies.

14. Ensure mental health community link-up; consider psychiatric, nursing home care intervention.Evaluation of Expected Outcomes

A. Patient

1. Patient safety will be maintained.

2. Patients with severe depression will be evaluated by psychiatric services.

3. Patients will report a reduction of symptoms that are indicative of depression. A reduction in the GDS score will be evident and suicidal thoughts or psychosis will resolve.

4. Patients daily functioning will improve.

B. Health care provider

1. Early recognition of patient at risk, referral, and interventions for depression, and documentation of outcomes will be improved.

C. Institution

1. The number of patients identified with depression will increase.

2. The number of in-hospital suicide attempts will not increase.

3. The number of referrals to mental health services will increase.

4. The number of referrals to psychiatric nursing home care services will increase.

5. Staff will receive ongoing education on depression recognition, assessment, and interventions

ALMA ROSE A. DEVELOS

ELECTIVE 2

BSN 4-2

Submitted to: Maam Wilma D. Ymasa


A. Assess and document all older adult patients for intrinsic risk factors to fall:

1. Advancing age, especially if older than 75

2. History of a recent fall

3. Specific co-morbidities: dementia, hip fracture, Type II diabetes, Parkinson's disease, arthritis, and depression

4. Functional disability: use of assistive device

5. Alteration in level of consciousness or cognitive impairment

6. Gait, balance, or visual impairment

7. Use of high-risk medications

8. Urge urinary incontinence

9. Physical restraint use

10. Bare feet or inappropriate footwear

11. Identify risks for significant injury due to current use of anticoagulants such as Coumadin, Plavix, or aspirin and/or those with osteoporosis or risks for osteoporosis

B. Assess and document patient-care environment routinely for extrinsic risk factors to fall and institute corrective action:

1. Floor surfaces for spills, wet areas, unevenness

2. Proper level of illumination and functioning of lights (night light works)

3. Table tops, furniture, beds are sturdy and are in good repair

4. Grab rails and grab bars are in place in the bathroom

5. Use of adaptive aides work properly and are in good repair

6. Bedrails do not collapse when used for transitioning or support

7. Patient gowns/clothing do not cause tripping

8. IV poles are sturdy if used during ambulation and tubing does not cause tripping.

C. Perform a PFA following a patient fall to identify possible fall causes (if possible, begin the identification of possible causes within 24 hours of a fall) as determined during the immediate, interim, and longitudinal post-fall intervals. Because of known incidences of delayed complication of falls, including fractures, observe all patients for about 48 hours after an observed or suspected fall.

1. Perform a physical assessment of the patient at the time of the fall, including vital signs (which may include orthostatic blood pressure readings), neurological assessment, and evaluation for head, neck, spine, and/or extremity injuries.

2. Once the assessment rules out any significant injury:

Obtain a history of the fall by the patient or witness description and document

Note the circumstances of the fall: location, activity, time of day, and any significant symptoms

Review of underlying illness and problems

Review medications

Assess functional, sensory, and psychological status

Evaluate environmental conditions

Review risk factors for falling

In the acute-care setting, an integrated multidisciplinary team (consisting of the physician, nurse, health care provider, risk manager, physical therapist, and other designated staff) plans care for the older adult, at risk for falls or who has fallen, hinged on findings from an individualized assessment.

The process approach to an individualized PFA includes use of standardized measurement tools of patient risk in combination with a fall-focused history and physical examination, functional assessment, and review of medications. When plans of care are targeted to likely causes, individualized interventions are likely to be identified. If falling continues despite attempts at individualized interventions, the standard of care warrants a reexamination of the older adult and their falls.

Nursing Care Strategies

A. General safety precaution and fall prevention measures that apply to all patients, especially older adults:

1. Assess the patient care environment routinely for extrinsic risk factors and institute appropriate corrective action.

Use standardized environmental checklists to screen; document findings.

Communicate findings to risk managers, housekeeping, maintenance department, all staff and hospital administration, if needed.

Re-evaluate environment for safety.

2. On admission, assess/screen older adult patient for multifactorial risk factors to fall, following a change in condition, on transfer to a new unit, and following a fall.

Use standardized or empirically tested fall-risk tools in conjunction with other assessment tools to evaluate risk for falling.

Document findings in nursing notes, interdisciplinary progress notes, and the problem list.

Communicate and discuss findings with interdisciplinary team members.

In the interdisciplinary discussion, include review and reduction or elimination of high-risk medications associated with falling.

As part of falls protocol in the facility, flag the chart or use graphic or color display of the patient's risk potential to fall.

Communicate to the patient and the family caregiver identified risk to fall and specific interventions chosen to minimize the patients risk.

Include patient and family members in the interdisciplinary plan of care and discussion about fall-prevention measures.

Promote early mobility and incorporate measures to increase mobility, such as daily walking, if medically stable and not otherwise contraindicated.

Upon transfer to another unit, communicate the risk assessment and interventions chosen and their effectiveness in fall prevention.

Upon discharge, review with the older patient and or family caregiver the fall risk factors and measures to prevent falls in the home. Provide patient literature/brochures if available. If not readily available, refer to the internet for appropriate web sites and resources.

Explore with the older patient and/or family caregiver avenues to maintain mobility and functional status; consider referral to home-based exercise or group exercises at community senior centers. If discharge is planned to a subacute or rehabilitation unit, label the older adult's mobility status, functional status, and other forms of activity in the home to increase gait or balance on the transfer form.

3. Institute general safety precautions according to facility protocol, which may include:

Referral to a falls prevention program

Use of a low-rise bed that measures 14 inches from floor

Use of floor mats if patient is at risk for serious injury, such as osteoporosis

Easy access to call light

Minimization and/or avoidance of physical restraints

Use of personal or pressure sensors alarms

Increased observation and surveillance

Use of rubber-soled heeled shoes or nonskid slippers

Regular toileting at set intervals and/or continence program; provide easy access to urinals and bedpans

Observation during walking rounds or safety rounds

Use of corrective glasses for walking

Reduction of clutter in traffic areas

Early mobility program

4. Provide staff with clear, written procedures describing what to do when a patient fall occurs.B. Identify specific patients requiring additional safety precautions and/or evaluation by a specialist, or:

Those with impaired judgment or thinking due to acute or chronic illness (delirium, mental illness)

Those with osteoporosis, at risk for fracture

Those with current hip fracture

Those with current head or brain injury (standard of care)

C. Review and discuss with interdisciplinary team findings from the individualized assessment and develop a multidisciplinary plan of care to prevent falls

Communicate to the physician or advance practice nurse important PFA findings

Monitor the effectiveness of the falls prevention interventions instituted.

Following a patient's fall, observe for serious injury due to a fall and follow facility protocols for management (standard of care).

Following a patient's fall, monitor vital signs, level of consciousness, neurological checks, and functional status per facility protocol. If significant changes in patient's condition occurs, consider further diagnostic tests such as plain film x-rays, CT scan of the head/spine/extremity, neurological consultation, and /or transfer to a specialty unit for further evaluation (standard of care).


A. Patients:

1. Safety will be maintained. 2. Falls will be avoided.3. Will not develop serious injury outcomes from a fall if it occurs.4. Will know their risks for falling.5. Will be prepared on discharge to prevent falls in their homes.6. Prehospitalization level of mobility will continue.7. Who develops fall-related complications such as injury or change in cognitive function will be promptly assessed and treated to prevent adverse outcomes.

B. Nursing Staff:

1. Will be able to accurately detect, refer, and manage older adults at risk for falling or who have experienced a fall.2. Will integrate into their practice comprehensive assessment and management approaches for falls prevention in the institution.3. Will gain appreciation for older adults unique experience of falling and how it influences their daily living, functional, physical, and emotional status.4. Educate older adult patients anticipating discharge about falls prevention strategies.

Follow-up Monitoring of Condition

A. Monitor fall incidence and incidences of patient injury due to a fall, comparing rates on the same unit over time.

B. Compare falls per patient month against national benchmarks available in the National Database of Nursing Quality Indicators.

C. Incorporate continuous quality improvement criteria into falls prevention program.

D. Identify falls team members and roles of clinical and nonclinical staff.

E. Educate patient and family caregivers about falls prevention strategies so they are prepared for discharge.

CZARINA KAYE F. SAPELINO

ELECTIVE 2 BSN 4-2

MAAM WILMA D. YMASA

EVIDENCED- BASED NURSING PRACTICE

IN GERIATRIC NURSING

-DELIRIUM-


A. Assess for risk factors

1. Baseline or pre-morbid cognitive impairment (see Chapter 8, Assessing Cognitive Function)2. Medications review (see Chapter 17, Reducing Adverse Drug Events)3. Pain (see Chapter 14, Pain Management)4. Metabolic disturbances (hypoglycemia, hypercalcemia, hyponatremia, hypokalemia)5. Hypoperfusion/hyponoxemia (BP, capillary refill, SpO2)6. Dehydration (physical signs/symptoms, intake/output, Na+, BUN/Cr)7. Infection (fever, WBCs with differential, cultures)8. Environment (sensory overload or deprivation, restraints)9. Impaired mobility10. Sensory impairment (vision, hearing)

B. Features of delirium -assess every shift (see "Resources" for validated instruments)

1. Acute onset; evidence of underlying medical condition2. Alertness: Fluctuates from stuporous to hypervigilant3. Attention: Inattentive, easily distractible, and may have difficulty shifting attention from one focus to another; has difficulty keeping track of what is being said4. Orientation: Disoriented to time and place; should not be disoriented to person5. Memory: Inability to recall events of hospitalization and current illness; unable to remember instructions; forgetful of names, events, activities, current news, and so on6. Thinking: Disorganized thinking; rambling, irrelevant, incoherent conversation; unclear or illogical flow of ideas; or unpredictable switching from topic to topic; difficulty in expressing needs and concerns; speech may be garbled7. Perception: Perceptual disturbances such as illusions and visual or auditory hallucinations; and misperceptions such as calling a stranger by a relatives name8. Psychomotor activity: May fluctuate between hypoactive, hyperactive, and mixed subtypes


(based on protocols in multicomponent delirium prevention studies)

A. Obtain geriatric consultation.

B. Eliminate or minimize risk factors

1. Administer medications judiciously; avoid high-risk medications

2. Prevent/promptly and appropriately treat infections.3. Prevent/promptly treat dehydration and electrolyte disturbances.4. Provide adequate pain control5. Maximize oxygen delivery (supplemental oxygen, blood, and BP support as needed).6. Use sensory aids as appropriate.7. Regulate bowel/bladder function.8. Provide adequate nutrition

C. Provide a therapeutic environment.

1. Foster orientation: frequently reassure and reorient patient (unless patient becomes agitated); use easily visible calendars, clocks, caregiver identification; carefully explain all activities; communicate clearly2. Provide appropriate sensory stimulation: quiet room; adequate light; one task at a time; noise-reduction strategies3. Facilitate sleep: back massage, warm milk or herbal tea at bedtime; relaxation music/tapes; noise-reduction measures; avoid awakening patient 4. Foster familiarity: encourage family/friends to stay at bedside; bring familiar objects from home; maintain consistency of caregivers; minimize relocations5. Maximize mobility: avoid restraints and urinary catheters; ambulate or active ROM three times daily6. Communicate clearly, provide explanations7. Reassure and educate family

8. Minimize invasive interventions9. Consider psychotropic medication as a last resort for agitation


A. Patient

1. Absence of delirium or2. Cognitive status returned to baseline (prior to delirium)3. Functional status returned to baseline (prior to delirium)4. Discharged to same destination as prehospitalization

B. Health Care Provider

1. Regular use of delirium screening tool2. Increased detection of delirium3. Implementation of appropriate interventions to prevent/treat delirium from standardized protocol4. Decreased use of physical restraints5. Decreased use of antipsychotic medications6. Increased satisfaction in care of hospitalized older adults

C. Institution

1. Staff education and interprofessional care planning2. Implementation of standardized delirium screening protocol

3. Decreased overall cost4. Decreased length of stays5. Decreased morbidity and mortality6. Increased referrals and consultation to above specified specialists7. Improved satisfaction of patients, families, and nursing staffFollow-up Monitoring of Condition

A. Decreased delirium to become a measure of quality care

B. Incidence of delirium to decrease

C. Patient days with delirium to decrease

D. Staff competence in recognition and treatment of acute confusion/delirium

E. Documentation of a variety of interventions for acute confusion/delirium

Na+ = sodium; BUN/Cr = blood urea nitrogen/creatinine ratio; BP = blood pressure;Hgb/Hct = hemoglobin and hematocrit; SpO2 = pulse oxygen saturation;WBCs = white blood cells; URI = upper respiratory infection; UTI = urinary tract infection; ROM= range of motion

SITTIE AINNIE ALYSSA S. ALI

ELECTIVE 2

BSN 4-2

MAAM WILMA D. YMASA

EVIDENCED-BASED NURSING PRACTICE IN GERIATRICS

-PAIN-

Assessment Parameters

A. Assumptions

1. Most hospitalized older patients suffer from both acute and persistent pain.

2. Older adults with cognitive impairment experience pain but are often unable to verbalize it.

3. Both patients and health care providers have personal beliefs, prior experiences, insufficient knowledge, and mistaken beliefs about pain and pain management that (a) influence the pain management process, and (b) must be acknowledged before optimal pain relief can be achieved.

4. Pain assessment must be regular, systematic, and documented to accurately evaluate treatment effectiveness.

5. Self-report is the gold standard for pain assessment.

B. Strategies for Pain Assessment

1. Initial, quick pain assessment

Assess older adults who who present with acute pain of moderate-to-severe intensity or who appear to be in distress.

Assess pain localization, intensity, duration, quality, and onset.

Assess vital signs. If changes in vital signs are absent, do not assume that pain is absent

2. Comprehensive pain assessment

Review medical history, physical exam, and laboratory and diagnostic tests in order to understand sequence of events contributing to pain.

Assess cognitive status (e.g., dementia, delirium), mental state (e.g., anxiety, agitation, depression), and functional status. If there is evidence of cognitive impairment, do not assume that the patient cannot provide a self-report of pain. Be prepared to augment self-report with observational measures and proxy report using the hierarchical approach.

Assess present pain, including intensity, character, frequency, pattern, location, duration, and precipitating and relieving factors.

Assess pain history, including prior injuries, illnesses, and surgeries; pain experiences; and pain interference with daily activities.

Review medications, including current and previously used prescription drugs, over-the-counter drugs, and home remedies. Determine which pain control methods have previously been effective for the patient. Assess patient's attitudes and beliefs about use of analgesics, adjuvant drugs, and nonpharmacological treatments.

Use a standardized tool to assess self-reported pain. Choose from published measurement tools and recall that older adults may have difficulty using 10-point visual analog scales. Vertical verbal descriptor scales or faces scales may be more useful with older adults.

Assess pain regularly and frequently but at least every 4 hours. Monitor pain intensity after giving medications to evaluate effectiveness.

Observe for nonverbal and behavioral signs of pain, such as facial grimacing, withdrawal, guarding, rubbing, limping, shifting of position, aggression, agitation, depression, vocalizations, and crying. Also watch for changes in behavior from the patient's usual patterns.

Gather information from family members about the patient's pain experiences. Ask about the patient's verbal and nonverbal/behavioral expressions of pain, particularly in older adults with dementia.

When pain is suspected but assessment instruments or observation is ambiguous, institute a clinical trial of pain treatment (i.e., in persons with dementia). If symptoms persist, assume pain is unrelieved and treat accordingly.

C. Assessment Tools


A. General Approach

1. Pain management requires an individualized approach.

2. Older adults with pain require comprehensive, individualized plans that incorporate personal goals, specify treatments, and address strategies to minimize the pain and its consequences on functioning, sleep, mood, and behavior.

B. Pain Prevention

1. Develop a written pain treatment plan upon admission to the hospital, or prior to surgery or treatments. Help the patient to set realistic pain treatment goals, and document the goals and plan.

2. Assess pain regularly and frequently to facilitate appropriate treatment.

3. Anticipate and aggressively treat for pain before, during, and after painful diagnostic and/or therapeutic treatments. Administer analgesics 30 minutes prior to activities.

4. Educate patients, families, and other clinicians to use analgesic medications prophylactically prior to and after painful procedures.

5. Educate patients and families about pain medications and their side effects; adverse effects; and issues of addiction, dependence, and tolerance.

6. Educate patients to take medications for pain on a regular basis and to avoid allowing pain to escalate.

7. Educate patients, families, and other clinicians to use nonpharmacological strategies to manage pain, such as relaxation, massage, and heat/cold.

C. Treatment Guidelines

1. Pharmacologic

a. Administer pain drugs on a regular basis to maintain therapeutic levels. Use PRN (as needed) medications for breakthrough pain.

b. Document treatment plan to maintain consistency across shifts and with other care providers.

c. Use equianalgesic dosing and the WHO three-step ladder to obtain optimal pain relief with fewer side effects.

d. For postoperative pain, choose the least invasive route. Intravenous analgesics are the first choice after major surgery. Avoid intramuscular injections. Transition from parenteral medications to oral analgesics when the patient has oral intake.

e. Choose the correct type of analgesic. Use opoids for treating moderate-to-severe pain and nonopoids for mild-to-moderate pain. Select the analgesic based on thorough medical history, comorbidities, other medications, and history of drug reactions.

f. Among nonopoid medications, acetaminophen is the preferred drug for treating mild-to-moderate pain. Guidelines recommend not exceeding 4 g per day (maximum 3 g/day in frail elders). The maximum dose should be reduced to 50%-75% in adults with reduced hepatic function or history of alcohol abuse.

g. The other major class of nonopoid medications, nonsteroidal anti-inflammatory drugs (NSAIDs), should be used with caution in older adults. Monitor for gastrointestinal (GI) bleeding and consider giving with a proton pump inhibitor to reduce gastric irritation. Also monitor for bleeding, nephrotoxicity, and delirium.

h. Older adults are at increased risk for adverse drug reactions due to age- and disease-related changes in pharmacokinetics and pharmacodynamics. Monitor medication effects closely to avoid overmedication or undermedication and to detect adverse effects. Assess hepatic and renal functioning.

2. Nonpharmacologic

a. Investigate older patients' attitudes and beliefs about, preference for, and experience with nonpharmacological pain-treatment strategies.

b. Tailor nonpharmacologic techniques to the individual.

c. Cognitive-behavioral strategies focus on changing the person's perception of pain (e.g., relaxation therapy, education, and distraction) and may not be appropriate for cognitively impaired persons.

d. Physical pain relief strategies focus on promoting comfort and altering physiologic responses to pain (e.g., heat, cold, TENS units) and are generally safe and effective.

3. Combination approaches that include both pharmacological and nonpharmacological pain treatments are often the most effective.

D. Follow-up Assessment

1. Monitor treatment effects within 1 hour of administration and at least every 4 hours.

2. Evaluate patient for pain relief and side effects of treatment.

3. Document patient's response to treatment effects.

4. Document treatment regimen in patient care plan to facilitate consistent implementation.

Expected Outcomes

A. Patient:

1. Will be either pain free or pain will be at a level that the patient judges as acceptable.

2. Maintains highest level of self care, functional ability, and activity level possible.

3. Experiences no iatrogenic complications, such as falls, GI upset/bleeding, or altered cognitive status.

B. Nurse:

1. Will demonstrate evidence of ongoing and comprehensive pain assessment.

2. Will document evidence of prompt and effective pain management interventions.

3. Will document systematic evaluation of treatment effectiveness.

4. Will demonstrate knowledge of pain management in older patients, including assessment strategies, pain medications, nonpharmacological interventions, and patient and family education.

C. Institution

1. Facilities/institutions will maintain strong institutional commitment and leadership to improve pain management. Evidence of institutional commitment include:

a. Providing adequate resources (including compensation for staff education and time; necessary materials)

b. Clear communication of how better pain management is congruent with organizational goals

c. Establishment of policies and standard operating procedures for the organization

d. Requiring clear accountability for outcomes

2. Facilities/institutions will establish an internal pain team of committed and knowledgeable staff who can lead quality improvement efforts to improve pain management practices.

3. Facilities/institutions will require evidence of documentation of pain assessment, intervention, and evaluation of treatment effectiveness. This includes adding pain assessment and reassessment questions to flow sheets and electronic forms.

Documents

Elective 2