Day 2 senior healthcare consultant conference

Dee Tucker RN, MS, GCNS-BCNursing Service

An Overall Assessment Tool of Older Adults

SPICES

SPICES

Use as a screen for the most frequently occurring health problems in hospitalized older adults

SPICES

Screen daily.Follow up with further assessment.

Initiate preventive and therapeutic interventions.

Prevent hospital-acquired complications!

Assessment Interventions

Sleep Disorders

Problems with Eating/Feeding, Pain

Incontinence

Cognition

Evidence of Falls, Mobility problems

Skin Breakdown

SPICES


Sleep Disorders

Restless or wake-sleep cycle disturbance

Sleep protocol Evaluate for cause & treat (pain, delirium, etc)

SPICES


Problems with Eating/Feeding, Pain

% food eaten for each meal last 24hrPO fluid intake amount

UOPWt if dailyLBM

If less than 50%

If less than 1.5 to 2 Liters; or NPO, or clear liquid diet for 24 hrs or more If less than 30 ml/hr

If gain 1-2 Kg in 24 hrsIf no BM in 3 days

SPICES


Incontinence Any episode

Foley catheter

Begin Toileting scheduleEvaluate for UTI DC’ing when

Cognition Any change in LOC, attentiveness, memory,

Evaluate for cause (pain, delirium, etc

SPICES


Evidence of Falls, Mobility problems

Orthostatic BP & pulse

Function & mobility as observed in last 24 hrsFalls- circumstances

If greater than 20 point drop in systolicIf below baseline, or declining

If occur

Skin Breakdown

Any change With risk or actual impairment

SPICES

SPICES Questions?

Tell me what you’ve learned.

Thank You

Atypical Disease Presentation in Older AdultsAtypical Disease Presentation in Older AdultsDee Tucker, MS, RN, GCNS-BCNursing AdministrationDee Tucker, MS, RN, GCNS-BCNursing Administration

Atypical Disease Presentation


By assessing older patients for atypical presentations, nurses provide appropriate interventions and prevent complications / crises.

By assessing older patients for atypical presentations, nurses provide appropriate interventions and prevent complications / crises.

Signs and SymptomsSigns and Symptoms

Learn baseline prior to illness Remember

aging changes

Recognize presenting symptoms

Baseline prior to illnessBaseline prior to illness

Variability

Verify

Frailty

Variability

Verify

Frailty

Aging EffectAging Effect

Non specific

Less acute

Slow to present

Non specific

Less acute

Slow to present

Presenting SymptomsPresenting Symptoms

Signs and symptoms in older patients are generalized and can represent any number of medical situations.



InfectionsInfections

Urinary Tract

Respiratory

Skin

UTIUTI

The older kidney has less concentrated urine.

•Kidneys do not conserve water as well

•Increased amount of drugs in blood

UTIUTI

Symptomstired, poor appetite, perhaps abdominal discomfort, perhaps foul smell to urine

Signsincontinence, trips/fall, less sharp thinking, perhaps temperature

Laburine- WBC, bacteria; perhaps WBCs elevated in blood work

Symptomstired, poor appetite, perhaps abdominal discomfort, perhaps foul smell to urine

Signsincontinence, trips/fall, less sharp thinking, perhaps temperature

Laburine- WBC, bacteria; perhaps WBCs elevated in blood work

Respiratory InfectionRespiratory Infection

BLUE represents amount of air inhaled

RED represents lungsPINK represents the diaphragm

Respiratory InfectionRespiratory InfectionSymptoms

tired, poor appetite, perhaps cough, perhaps shortness of breathe

Signsrespiratory rate, tripping/fall, perhaps temperature; less sharp thinking

LabWBC ?, cxr ?,

Symptomstired, poor appetite, perhaps cough, perhaps shortness of breathe

Signsrespiratory rate, tripping/fall, perhaps temperature; less sharp thinking

LabWBC ?, cxr ?,

Skin InfectionSkin Infection

Symptomstired, some tenderness

Signsincreased color, maybe swelling, drainage

Labblood- ?

Symptomstired, some tenderness

Signsincreased color, maybe swelling, drainage

Labblood- ?



Cardiac IssuesCardiac Issues

Heart Failure with pulmonary edema

Myocardial Infarction

Pulmonary Embolism

Heart Failure with Pulmonary Edema

Heart Failure with Pulmonary Edema

Symptomstired, poor appetite, perhaps shortness of breathe or leg swelling

Signsperhaps rales; less sharp thinking

Lab

Symptomstired, poor appetite, perhaps shortness of breathe or leg swelling

Signsperhaps rales; less sharp thinking

Lab

Myocardial InfarctionMyocardial Infarction

Symptomsfatigue, weak, restless, shortness of breath, perhaps pain

Signsperhaps syncope, less mental sharpness, perhaps confusion

Labcardiac enzymes

Symptomsfatigue, weak, restless, shortness of breath, perhaps pain

Signsperhaps syncope, less mental sharpness, perhaps confusion

Labcardiac enzymes

Pulmonary EmboliPulmonary Emboli

Symptoms: perhaps chest pain with inspiration, perhaps shortness of breath

Signs: elevated HR, tachypnea, rales; perhaps LE symptoms of DVT, dyspnea

Lab: positive D-dimer; perhaps ABGs changes

Symptoms: perhaps chest pain with inspiration, perhaps shortness of breath

Signs: elevated HR, tachypnea, rales; perhaps LE symptoms of DVT, dyspnea

Lab: positive D-dimer; perhaps ABGs changes

CaseCase

86 yo man is admitted for c/o progressive weakness and fatigue: unable to carry out his normal daily activities, 2 falls.

He lives with his wife in their home. He was independent in all ADL’s and IADLs. He enjoyed his garden daily and worked part time at a real estate office.

86 yo man is admitted for c/o progressive weakness and fatigue: unable to carry out his normal daily activities, 2 falls.

He lives with his wife in their home. He was independent in all ADL’s and IADLs. He enjoyed his garden daily and worked part time at a real estate office.

CaseCase

He is cooperative, pleasant and looks quite well. No history of dyspnea or coughing. He has an IV going and waiting for more lab tests. He requires assistance to get to the bathroom.

Report from night shift: he has bilateral basilar rales; temp 99.2, Resp 20; BP unchanged; remains weak; up to bathroom numerous times; no complaints of pain but did not sleep well and is restless

He is cooperative, pleasant and looks quite well. No history of dyspnea or coughing. He has an IV going and waiting for more lab tests. He requires assistance to get to the bathroom.

Report from night shift: he has bilateral basilar rales; temp 99.2, Resp 20; BP unchanged; remains weak; up to bathroom numerous times; no complaints of pain but did not sleep well and is restless

Symptom Presentation in Older Adults

Symptom Presentation in Older Adults

Baseline: independent ADLs, IADLs, very active self sufficient; no dyspnea or cough

Symptomsfatigue, unable to do ADLs, requires assistance to ambulate to BR

Signsrestless, bilateral basilar rales, little sleep; Temp 99.2; resp 20

Lab: none available

Baseline: independent ADLs, IADLs, very active self sufficient; no dyspnea or cough

Symptomsfatigue, unable to do ADLs, requires assistance to ambulate to BR

Signsrestless, bilateral basilar rales, little sleep; Temp 99.2; resp 20

Lab: none available

Clinical PearlsClinical Pearls

Symptoms: vague, less acute, slow to present

Compare to normal baseline

Assess for potential causes

Symptoms: vague, less acute, slow to present

Compare to normal baseline

Assess for potential causes

Delirium:Can You Recognize Acute

Confusion?

Dee Tucker, MS, RN, GCNS-BC

Nursing Administration

Delirium: Risk

Normal Aging Changes

Environment

Medications

Medical conditions

Procedures

3 Types of Delirium

• Hyperalert, hyperactive

• Hypoactive, hypoalert

• Mixed

Prevention

• Ensure hydration and nutrition

• Mobilize

• Support Cognition

• Enhance sleep

• Use sensory aids

Assessment

Baseline

Cognition

Function

Mobility

Assessment for Delirium

CAM Confusion Assessment Method

1. Acute onset; fluctuating

2. Inattentive

3. Disorganized thinking

4. ALOC

Delirium = 1 & 2 are present with either #3 or #4

CAM

1st Sudden Onset

After admission

Prior to admission

If present, go on to #2

CAM

2nd Inattention

Tests of attention

• Count backwards from 20.

• State days of week forward & backward

Alternatives for patients who can not speak

If present, go on to #3

CAM

3rd Disorganized Thinking

Clinical evaluation of conversation

Sets of Questions

Present or not, go on to # 4

CAM

4th Altered Level of Consciousness

Anything other than alert = positive

• Hyperalert

• Lethargic

• Stuporous, comatose

CAM

CAM Confusion Assessment Method1. Acute onset; fluctuating2. Inattentive3. Disorganized thinking4. ALOC

Delirium = 1 & 2 are present with either #3 or #4

Assessment Frequency

• Admission

• Daily

• With behaviors changes

Documenting

Specific behaviors -Avoid general terms i.e. confusion, disoriented

Alert vs attentive

Never Event- will be one

Geriatric Tools and Assessment : enter under “Documents”

Interventionswith Delirium

Collaboration

Safe environment

Prevent complications


Collaboration

Ask pharmacist to review meds

Check labs

Notify MD / share what done and think

Educate family


Safe EnvironmentOrient frequently, Reassure, familyRoom near nurses station, quietMinimize equipmentAvoid restraints- includes IV, foleyContinuity- routine, staffSensory aids


Prevent ComplicationsHydration/ Fluid balanceNutritionDeconditioningPain managementMonitor O2, CV functionEnhance sleep

What Do You Think?

1. Nurses must learn to recognize signs of delirium in older adults because:a. It is an indication of the progression of chronic

illness.b. It is a indication of serious illness that needs to be

evaluated promptly.c. It is common but insignificant finding which does

not require medical evaluation.d. If nurses recognize it, then physicians will not be

called so often

What Do You Think?

2. The following are possible precipitating causes of delirium in elders:a. A urinary tract infection.

b. Adverse reaction to a drug.

c. Dehydration.

d. All of the above.

What Do You Think?

3. Patients with dementia are at increased risk for developing delirium.

a. False

b. True

What Do You Think?

4. What is the cardinal sign of delirium?

a. Change in baseline cognition and function within hours or days.

b. Inability to remember recent events.

c. Forgetting an appointment.

d. Answering "I don't know" frequently on the Mini-Mental Status Exam.

What Do You Think?

5. Which of the following predisposes older adults to delirium?a. Cognitive impairment

b. Sensory losses

c. Severe illness

d. Dehydration

e. All of the above

Delirium

ALL older patients at risk

Baseline prior to illness

Use CAM

Prevention / Intervention

DepressionDepression

IncidenceIncidence

60 million Americans greater than 65 yrs.60 million Americans greater than 65 yrs.

Only 10% of these receive treatmentOnly 10% of these receive treatment

Major public health problem – leading to Major public health problem – leading to impaired functional status, increased impaired functional status, increased mortality, and excessive use of healthcare mortality, and excessive use of healthcare resources.resources.

DefinitionDefinition

Clinical syndrome characterized by lower Clinical syndrome characterized by lower mood tone, difficulty thinking, and somatic mood tone, difficulty thinking, and somatic changes precipitated by feelings of loss changes precipitated by feelings of loss and / or guilt.and / or guilt.

Symptoms of DepressionSymptoms of Depression

Feeling of worthlessness or sadnessFeeling of worthlessness or sadnessLoss of interest or pleasure in activities Loss of interest or pleasure in activities previously enjoyedpreviously enjoyedLoss of energy - fatigueLoss of energy - fatigueIrritability, agitationIrritability, agitationChange in appetiteChange in appetiteSleep problemsSleep problemsCognition difficultiesCognition difficultiesSuicidal ideationSuicidal ideation

Diagnosis ChallengesDiagnosis Challenges

Concurrent medical illness with Concurrent medical illness with overlapping symptoms of depressionoverlapping symptoms of depression

Medication side effectsMedication side effects

Impaired communication in the elderlyImpaired communication in the elderly

Multiple somatic complaintsMultiple somatic complaints

Focus on complex medical issuesFocus on complex medical issues

StigmaStigma

Risk FactorsRisk Factors

Female sexFemale sex

Social isolationSocial isolation

Unemployment or retirementUnemployment or retirement

Widowed, divorced, or separatedWidowed, divorced, or separated

Serious medical conditions, especially Serious medical conditions, especially vascular problemsvascular problems

Uncontrolled painUncontrolled pain

Causes of DepressionCauses of Depression

Many different theories, Many different Many different theories, Many different causescauses

Brain neurotransmitter imbalance – Brain neurotransmitter imbalance – predominately serotonin and dopaminepredominately serotonin and dopamine

Alcohol and drugsAlcohol and drugs

HeredityHeredity

MedicationsMedications

IllnessesIllnesses

Vascular DepressionVascular Depression

Importance of chronic ischemic cerebral Importance of chronic ischemic cerebral changes only recently recognizedchanges only recently recognized

Most prominent in late life depressionMost prominent in late life depression

Associated with diseases such as CAD, Associated with diseases such as CAD, diabetes, strokediabetes, stroke

Pharmacologic TreatmentPharmacologic Treatment

SSRI’s – Celexa, Lexapro, Zoloft, Paxil, ProzacSSRI’s – Celexa, Lexapro, Zoloft, Paxil, Prozac

SNRI’s – Effexor, CymbaltaSNRI’s – Effexor, Cymbalta

DNRI’s – WellbutrinDNRI’s – Wellbutrin

Noradrenergic and specific serotonergic –Noradrenergic and specific serotonergic –

RemeronRemeron

Tricyclics – Elavil, Sinequan, PamelorTricyclics – Elavil, Sinequan, Pamelor

MAO inhibitors – Nardil, Parnate MAO inhibitors – Nardil, Parnate

Other Medication ConsiderationsOther Medication Considerations

Start low and go slowStart low and go slow

Explain temporary side effects to encourage Explain temporary side effects to encourage compliancecompliance

May not see full therapeutic benefits for several May not see full therapeutic benefits for several weeks (6-12)weeks (6-12)

Assure close monitoring every 1-2 weeksAssure close monitoring every 1-2 weeks

Don’t discontinue suddenlyDon’t discontinue suddenly

Monotherapy better in the elderlyMonotherapy better in the elderly

Consider $$COST$$Consider $$COST$$

Other Forms of TreatmentOther Forms of Treatment

Psychotherapy : individual and/or groupPsychotherapy : individual and/or group

Problem – Medicare and other insurances Problem – Medicare and other insurances offer incomplete coverage (50% allowable)offer incomplete coverage (50% allowable)

Family involvement (unless they are the Family involvement (unless they are the problem)problem)

Church or community involvementChurch or community involvement

ECTECT

What can we do ?What can we do ?

ScreeningScreeningSPICESSPICESEnhance physical function and social Enhance physical function and social supportsupportEncourage daily participation in therapiesEncourage daily participation in therapiesRec. Therapy consultRec. Therapy consultAssist with problem solvingAssist with problem solvingProvide emotional supportProvide emotional support

““SIG-E-CAPS”SIG-E-CAPS”

Acronym for evaluating patient’s progressAcronym for evaluating patient’s progress S Sleep disturbancesS Sleep disturbances I Interest in activitiesI Interest in activities G Guilt and/or low self esteemG Guilt and/or low self esteem E Energy E Energy C ConcentrationC Concentration A Appetite changesA Appetite changes P Psychomotor changes (agitation/retardation)P Psychomotor changes (agitation/retardation) S SuicideS Suicide

Nutrition and HydrationNutrition and Hydrationin the Older Adultin the Older Adult

DefinitionsDefinitions

Malnutrition: any disorder of nutrition status, including disorders resulting from inadequate intake (not getting enough in), improper metabolism, or over-nutrition (eating too much!).

DemographicsDemographics

Malnutrition in Older Adults:

Independent Living: 1% TO 15%

Institutionalized: 25% TO 85%

Hospitalized: 35% TO 65%

Increased RisksIncreased Risks

Older adults who are malnourished are more likely to experience:Longer hospital staysIncreased hospital costsDiminished muscle strengthFunctional impairments

Increased RisksIncreased Risks

Poor wound healing and development of new pressure ulcers

InfectionsPost operative complicationsDeath

Factors InvolvedFactors Involved

Older adults are at increased risk for malnutrition due to dietary, economic, psychosocial and physiological factors.

Physiological FactorsPhysiological Factors

Chronic illnesses Medications Poor oral health Disability GI issues Changes in taste and reduced sense of

thirst Other senses: vision, hearing, smell

Screening and AssessmentScreening and Assessment

Assessments should includeBaseline- nutritional patterns, abilitiesLab results- albumin, prealbuminUnintentional weight loss prior to

admission


Both current weight and weight history are important!!

Loss of 10 lbs over 6 month period – intentional or unintentional – is a red flag needing further assessment


Calorie counts

Less than 50% eaten document and act!


Inconsistencies between reported diet and what you see physically (may indicate poverty or elder neglect/abuse)

DehydrationDehydration

Quickly becomes a critical problem during periods of illness and is often a primary or secondary reason why the patient is in the hospital

Hydration status must be performed on all older people; I/Os are very important!

If a patient is not eating well, chances are they are also not drinking well.


Elderly may present differently than younger people, symptoms can be subtle:Irritability, confusion, lightheadedness,

change in mental status, headache, loss of appetite, lethargy (very tired) or fatigue, low urine output or dark urine, constipation, fecal impaction, infection, muscle weakness


Poor skin turgor, dry mouth and lips, subtle change in baseline: families may report “Mom doesn’t seem herself today”


Check Orthostatics. A fall in blood pressure of 20MM HG systolic (when going from lying to standing) and/or a rise in pulse by 15 beats per minute often means a person is dehydrated.


Lab tests: serum sodium (hypo or hypernatremia), potassium (hyperkalemia), creatinine (not as reliable in elderly), blood urea nitrogen (BUN), urine specific gravity, and urine electrolytes


Alleviate dry mouth:Avoid caffeineAvoid dry, bulky, spicy, salty foodsSugarless hard candy or chewing gum to

stimulate saliva (not for patients with dementia or dysphagia)

Applying petroleum jelly to lips or denturesFrequent small mouthfuls of waterArtificial saliva

Be ProactiveBe Proactive

Improve oral intake:Mealtime checksEncourage family members Small, frequent intakePain medsPleasant environmentOOB


Cues and GesturesHand over older person’s handPantomime gesturesSit across (Model eating behavior)

Use adaptive devices and make sure they work: eyeglasses, hearing aids, dentures, sports bottles, straws and cups with lids (tremors)

Allow time – use finger foods


Difficulty in swallowing referred to SLP. Dysphagia occurs in advancing dementia

and patient may eventually lose the ability to swallow and eat or drink.

Supplements

What Do You Think?What Do You Think?

Which of these situations is an example of nosocomial malnutrition?

1. Decreased intake related to a disease process

2. Failure to replace meals held for tests3. Anorexia related to an underlying

eating disorder


Malnutrition in a hospital usually refers to

1. Carbohydrate- fat intake2. Protein-carbohydrate intake3. Fat-protein intake4. Protein-calorie intake


A patient who fails to consume adequate calories and protein is at increased risk for which of these complications?

1. Thromboembolism2. Heart failure3. Hepatitis


A patient who develops hypoalbuminemia related to protein deficiency should be monitored for toxicity to which of these meds?

1. Warfarin2. Dilantin3. Meperidine4. Digoxin


Which of these approaches would you use with a patient whose appetite deteriorates throughout the day?

1. Limit stimulation at meals2. Encourage a big breakfast3. Reduce physical activity4. Offer double portions

Discharge PlanningDischarge Planning

Collaboration is keyCollaboration is key

Goals of SessionGoals of Session

1.1. Clarify Myths and FactsClarify Myths and Facts

2.2. Purpose of D/C Planning Purpose of D/C Planning

3.3. High Risk Triggers for D/C PlanningHigh Risk Triggers for D/C Planning

4.4. Basic Needs are Assessments and Basic Needs are Assessments and Resource Management Resource Management

5.5. Case ScenariosCase Scenarios

Myths and FactsMyths and Facts

• 1. Only the elderly patient need D/C Planning. T__F__1. Only the elderly patient need D/C Planning. T__F__

• 2. The MD must order D/C Planning for all patients needing 2. The MD must order D/C Planning for all patients needing these services. T__ F__these services. T__ F__

• 3. Patients are always truthful about their D/C 3. Patients are always truthful about their D/C Planning needs. T__ F__Planning needs. T__ F__

• 4. A referral to Social Worker is needed for D/C 4. A referral to Social Worker is needed for D/C Planning services. T__ F__Planning services. T__ F__

• 5. Hospitals must 5. Hospitals must provideprovide D/C Planning services to all D/C Planning services to all patients. T__ F___ patients. T__ F___

History of Discharge PlanningHistory of Discharge Planningbased on Regulatory Influencesbased on Regulatory Influences

• HCFAHCFA ( Health Care Financing Admin.) ( Health Care Financing Admin.)

• JCAHOJCAHO (Joint Commission on Accreditation of Healthcare Organizations (Joint Commission on Accreditation of Healthcare Organizations

• Abuse/ Neglect LegislationAbuse/ Neglect Legislation

• OBRA Act of 1987OBRA Act of 1987 (Omnibus Reconciliation Act) (Omnibus Reconciliation Act)

• Medicare Patient Transfer ActMedicare Patient Transfer Act

• Nondiscrimination in Post-Hosp. Referral to Home Health Agencies and Nondiscrimination in Post-Hosp. Referral to Home Health Agencies and other Entities other Entities (BBA/1997(BBA/1997))

• Medicare Discharge Notice Act 2007Medicare Discharge Notice Act 2007

Piedmont Hospital Discharge Planning PolicyPiedmont Hospital Discharge Planning Policy

• To promote To promote continuity of carecontinuity of care and support and support patients’ patients’ safetysafety for post hospital care and services. for post hospital care and services.

• Involves Involves high risk screeninghigh risk screening within 24 hrs. of within 24 hrs. of admission to the hospital.admission to the hospital.

• Must have documentation of Must have documentation of assessmentsassessments with a with a Plan.Plan.

• Recognition of Recognition of potential discharge delays.potential discharge delays.

• Discharge Rights NoticeDischarge Rights Notice and Appeal Rights and Appeal Rights

High Risk TriggersHigh Risk Triggers

• Patients over 70 years oldPatients over 70 years old

• Patients with LOS >7 daysPatients with LOS >7 days

• Chronic or serious illness such asChronic or serious illness such as CVA,CA, MI, THR, Closed Head/Spinal Cord Injury, HIV+/AIDS, CVA,CA, MI, THR, Closed Head/Spinal Cord Injury, HIV+/AIDS,

Coma, Multiple TraumaComa, Multiple Trauma

• Victim of abuse/neglectVictim of abuse/neglect

• Incompetent, Chronic non complianceIncompetent, Chronic non compliance

• Homeless, without insurance or without incomeHomeless, without insurance or without income

• Transferred from another facility: NH, LTAC, Hospice, Hosp. ALFTransferred from another facility: NH, LTAC, Hospice, Hosp. ALF

Standards for AssessmentsStandards for Assessments

• Expected outcome= Expected outcome= Plan for safe dischargePlan for safe discharge and and avoid inappropriate readmission.avoid inappropriate readmission.

• Accurate assessmentsAccurate assessments are essential to are essential to development of appropriate discharge plans.development of appropriate discharge plans.

• Patient componentsPatient components: : physical/functional/medical history; physical/functional/medical history; emotional/cognitive/behavioral; social/family emotional/cognitive/behavioral; social/family support; financialsupport; financial

Resource ManagementResource ManagementNeeds IdentifiedNeeds Identified

• In hospital and community resources optionsIn hospital and community resources options

• Problems that may affect discharge planningProblems that may affect discharge planning decisionsdecisions: delayed consult/ test /procedure/surgery/ lab : delayed consult/ test /procedure/surgery/ lab result; pt/family teaching for home care; multidisciplinary result; pt/family teaching for home care; multidisciplinary collaboration and communication ( need unit rounds & collaboration and communication ( need unit rounds & family meetings)family meetings)

• Flow chart of options based on needs identified from Flow chart of options based on needs identified from ongoing assessments.ongoing assessments.

• Post Hospital Follow-up needed to evaluate effectiveness Post Hospital Follow-up needed to evaluate effectiveness of D/C Plans of D/C Plans

Remember Discharge Planning is a process that we all Remember Discharge Planning is a process that we all must must shareshare and we and we need to collaborateneed to collaborate and and communicatecommunicate because because ““one day we will be on the receiving end of our one day we will be on the receiving end of our services”.services”.

Our goal is safe discharges and safe transitions out of the Our goal is safe discharges and safe transitions out of the hospital.hospital.

We want to team-up with you to improve communication We want to team-up with you to improve communication flow and links to resources.flow and links to resources.

What can we do better??What can we do better??

Thank youThank you

Case # 1Case # 1What would you do?What would you do?

• 86 yr. Old female who was visiting her daughter and was admitted to Hosp. 86 yr. Old female who was visiting her daughter and was admitted to Hosp. for N/V/Abd pain. She had temp 101. Hs. of HTN, AMI, Afib/on chronic for N/V/Abd pain. She had temp 101. Hs. of HTN, AMI, Afib/on chronic coumadin. DM/ diet regulated. coumadin. DM/ diet regulated.

• Admit orders were: Tel,VSq4.I&O;Lovenox SQq12.Reglan IVq6.Card & GI Admit orders were: Tel,VSq4.I&O;Lovenox SQq12.Reglan IVq6.Card & GI Consult. BL Cult pending. Home meds reconciliation done.Consult. BL Cult pending. Home meds reconciliation done.

• On 3 rd. day, MD projected for discharge in 1-2 days. All Test neg. VSS. Pt On 3 rd. day, MD projected for discharge in 1-2 days. All Test neg. VSS. Pt complained of pain intermittently, nutrition consult pending.complained of pain intermittently, nutrition consult pending.

• Pt lives alone in MD and a son lives closeby who checks on her and he is still Pt lives alone in MD and a son lives closeby who checks on her and he is still employed.employed.

• She has fallen a couple of times @home and has a housekeeper once a week She has fallen a couple of times @home and has a housekeeper once a week for chores, shopping, medical appt.for chores, shopping, medical appt.

• She was described as pleasant but confused @times but voiced being She was described as pleasant but confused @times but voiced being independent with ADLs. Socially, she attends church weekly and read her independent with ADLs. Socially, she attends church weekly and read her bible daily. She has 5 children whom she visited for weeks @ a time. bible daily. She has 5 children whom she visited for weeks @ a time.

Questions:Questions:Does this case meet High Risk for an assessment?Does this case meet High Risk for an assessment?This is your case today and you are aware that your Unit LOS is high.This is your case today and you are aware that your Unit LOS is high.The test and consults were negative and pt appear to be back @ baseline. MD The test and consults were negative and pt appear to be back @ baseline. MD

wrote in progress note that pt may be ready for d/c in 1-2 days. You have wrote in progress note that pt may be ready for d/c in 1-2 days. You have “rounds” today, what would you do or consider for this patient?“rounds” today, what would you do or consider for this patient?

What could be some resources for safety of her discharge @ this time?What could be some resources for safety of her discharge @ this time?

Case # 2Case # 2How would you handle this?How would you handle this?• Pt age 75 was found wandering and was admitted for CP, Pt age 75 was found wandering and was admitted for CP,

suffered cardiac arrest and was vent dependent for several suffered cardiac arrest and was vent dependent for several days. He is listed as John Doe.days. He is listed as John Doe.

• He is off vent but unable to recall his name or recall any He is off vent but unable to recall his name or recall any personal/ family information. Neuro and Rehab evals personal/ family information. Neuro and Rehab evals complete and pt is physically regaining independence but complete and pt is physically regaining independence but mental/ cognitive deficits remain.mental/ cognitive deficits remain.

• He has been in hospital 3 weeks and he is your patient today. He has been in hospital 3 weeks and he is your patient today. CM stated that pt is too independent for NH and will need CM stated that pt is too independent for NH and will need supervision for cognitive deficits but pt has no funds or supervision for cognitive deficits but pt has no funds or identification to apply for community resources.identification to apply for community resources.

• While in pt’s room, RN noticed that pt. was writing same While in pt’s room, RN noticed that pt. was writing same numbers repeatedly on a picture of a shirt. numbers repeatedly on a picture of a shirt.

Questions/ concernsQuestions/ concerns::How does he meet HR for D/C Planning?How does he meet HR for D/C Planning?What are some real barriers to safe discharge planning?What are some real barriers to safe discharge planning?What are some resources in the hospital and community to What are some resources in the hospital and community to

consider?consider?

IncontinenceIncontinence

Clinical Definition (UI):Clinical Definition (UI):

Urine loss of sufficient problem to be Urine loss of sufficient problem to be perceived as bothersome or it creates a perceived as bothersome or it creates a prompt desire to seek careprompt desire to seek care

An Estimated 16 million people in the U.S.An Estimated 16 million people in the U.S.

Over 50% Prevalence in the Over 50% Prevalence in the Institutionalized Elderly Institutionalized Elderly

Voiding PhysiologyVoiding Physiology

Cerebral CortexCerebral Cortex

Pontine Micturition Center Pontine Micturition Center

Micturition reflexMicturition reflex

Spinal Cord Pathways BladderSpinal Cord Pathways Bladder

Urethral SphincterUrethral Sphincter

““Head to Tail” assessmentHead to Tail” assessment

Bladder Differences by GenderBladder Differences by Gender

FemaleFemale Longitudinal SectionLongitudinal Section

Male MaleMale Male Longitudinal Section Lateral ViewLongitudinal Section Lateral View

Most Prevalent Types – Most Prevalent Types – Urinary IncontinenceUrinary Incontinence

Stress UI: urine loss due to sphincter Stress UI: urine loss due to sphincter dysfunction-dysfunction-Prolonged use of a Urinary catheterProlonged use of a Urinary catheter

Urge / Over-active BladderUrge / Over-active Bladder Mixed Incontinence: Stress UI + OABMixed Incontinence: Stress UI + OAB

AnAn EstimatedEstimated 90% 90% of UI = Stress, OAB, & Mixed of UI = Stress, OAB, & Mixed IncontinenceIncontinence

Total UI: complete loss of sphincter fxn or fistula Total UI: complete loss of sphincter fxn or fistula formationformation


Reflex UI: a spinal cord lesion, Reflex Arc Reflex UI: a spinal cord lesion, Reflex Arc is maintained (Bladder filling causes is maintained (Bladder filling causes bladder contraction)bladder contraction)

Retention w/ Overflow UIRetention w/ Overflow UIMixed Incontinence: Stress UI + OABMixed Incontinence: Stress UI + OAB

AnAn EstimatedEstimated 90% 90% of UI = Stress, OAB, & of UI = Stress, OAB, & Mixed IncontinenceMixed Incontinence


Total UI: complete loss of sphincter fxn or Total UI: complete loss of sphincter fxn or fistula formationfistula formation

Reflex UI: a spinal cord lesion, Reflex Arc Reflex UI: a spinal cord lesion, Reflex Arc is maintained (Bladder filling causes is maintained (Bladder filling causes bladder contraction)bladder contraction)

Retention w/ Overflow UIRetention w/ Overflow UI

Other types of Urinary IncontinenceOther types of Urinary Incontinence

Functional UI: normal voiding patterns & Functional UI: normal voiding patterns & normal bladder function; usually related to normal bladder function; usually related to cognitive status, motivation, and/or cognitive status, motivation, and/or mobility issues, mobility issues, environmentenvironment

ManagementManagementPrompted / Scheduled voidingPrompted / Scheduled voiding

Reversible Factors of Urinary Reversible Factors of Urinary Incontinence - “DIAPPERS”Incontinence - “DIAPPERS”

D – D – DeliriumDelirium I – I – Infection / IrritantsInfection / Irritants A – Atrophic urethritis / vaginitisA – Atrophic urethritis / vaginitis P – PharmaceuticalsP – Pharmaceuticals P – Psychological causesP – Psychological causes E – Endocrine causes (Excess urine)E – Endocrine causes (Excess urine) R R – Restricted Mobility– Restricted Mobility SS – Stool impaction – Stool impaction

Effects of Aging R/T ContinenceEffects of Aging R/T Continence

Increased nocturia (1-2x/night >60)Increased nocturia (1-2x/night >60)Bladder fills full at lower volumesBladder fills full at lower volumesReduced strength of bladder contractionsReduced strength of bladder contractions Increased irritability of bladderIncreased irritability of bladderDelayed recognition of bladder fillingDelayed recognition of bladder fillingAdequate fluid intake?Adequate fluid intake?

Indwelling Foley Catheters Indwelling Foley Catheters

30-40% of HAI30-40% of HAIRisk for UTI 1-2% for a single insertionRisk for UTI 1-2% for a single insertion Increases to 5-8% per day with indwelling Increases to 5-8% per day with indwelling

cathetercatheter

CAUTIs- one of CMS Never EventsCAUTIs- one of CMS Never Events

Foley Catheters in EDFoley Catheters in ED

CAUTIs- one of CMS Never EventsCAUTIs- one of CMS Never EventsMost effective method to prevent CAUTIs Most effective method to prevent CAUTIs

is to avoid indwelling cathtersis to avoid indwelling cathters If MUST have- then aseptic technique, If MUST have- then aseptic technique,

closed system, secured to legclosed system, secured to leg

Indications for a Urinary CatheterIndications for a Urinary Catheter Critically IllCritically Ill: Alteration in BP or volume status requiring : Alteration in BP or volume status requiring

continuous, accurate urine volume measurementcontinuous, accurate urine volume measurement Infection PreventionInfection Prevention: to prevent urine from soiling a Stage III or : to prevent urine from soiling a Stage III or

IV pressure ulcer or nearby operative siteIV pressure ulcer or nearby operative site Comfort careComfort care: for terminally ill patients: for terminally ill patients SurgerySurgery: patients going directly to the operating room: patients going directly to the operating room Procedures or TestsProcedures or Tests requiring an indwelling urinary catheter, requiring an indwelling urinary catheter,

removed at the conclusion of the procedure/testremoved at the conclusion of the procedure/test GU IndicationsGU Indications

Continuous bladder irrigation Continuous bladder irrigation Instillation of medication into the bladderInstillation of medication into the bladder Obstruction to the urinary tract distal to bladderObstruction to the urinary tract distal to bladder Drainage in patient with neurogenic bladder dysfunction, Drainage in patient with neurogenic bladder dysfunction,

hydronephrosis, and urinary retention not manageable by hydronephrosis, and urinary retention not manageable by other means (e.g., with clean intermittent catheterization)other means (e.g., with clean intermittent catheterization)

Aid in urologic surgery or other surgery in contiguous Aid in urologic surgery or other surgery in contiguous structuresstructures

Ordered by a urologist for a special purpose or difficult Ordered by a urologist for a special purpose or difficult insertioninsertion

When NOT to use a Catheter?When NOT to use a Catheter? An indwelling urinary catheter is An indwelling urinary catheter is notnot appropriate appropriate

for nursing convenience or for urinary for nursing convenience or for urinary incontinence in the absence of skin breakdown.incontinence in the absence of skin breakdown.

Use CAUTION = Use CAUTION = Prevent C.A.U.T.I.Prevent C.A.U.T.I.

C – Closed systemA – Aseptic mgmt of indwelling catheterU – Use standard precautionsT – Tubing secured to leg & clipped to sheetI – Indications (do I still need it?)O – Obstruction freeN – No dependent loops

EDED

• Gateway for most of our older patientsGateway for most of our older patients• Ability to initiate change in practice that will Ability to initiate change in practice that will

carry through the admissioncarry through the admission• Eliminate a risk that prolongs LOS and Eliminate a risk that prolongs LOS and

had financial impacthad financial impact

Definition of a Restraint:

• A physical restraint is any “manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move his/her arms, legs, body, or head freely.” (CMS- federal register, p 71389)

• A chemical restraint is a drug or medication used as a restriction to control the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.

• A forensic restraint is the use of handcuffs or other restrictive devices applied by law enforcement for custody, detention, and public safety reasons. They are not involved in the provision of health care by law enforcement.

Patient Rights

Every patient has the right to expect….• Care that is respectful, high-quality, considerate with

dignity

• Participation in decisions about treatment, benefits, risks, alternatives

• Consideration of personal beliefs and values

• provision for privacy

• Any restraint to be humanely and professionally administered

Negative Consequences of Restraint Use:

Physical• Pressure Ulcers• Decreased circulation• Muscle atrophy• Decreased metabolism• Increased incidence of

aspiration pneumonia• Constipation• Dehydration• Incontinence

Behavioral• Agitation, Confusion,

Anger• Emotional regression

and mental withdrawal• Loss of self esteem• Embarrassment or

humiliation• Loss of independence• Reduced social contact

Restraint Alternatives

Before an actual restraint can be used, the regulations require that other ways to handle the situation be tried first and documented such as:

• Companionship/supervision• Communication• Teaching• Change in Treatments• Diversion• Environmental changes

Alternatives for Patient Interference with Medical Devices

• Addressing the discomfort associated with the treatment in a quiet and calm way

• Explaining the situation/procedure or giving information about the problem

• Evaluate need for treatment device

• As soon as possible, initiate oral feeding, remove catheters and drains, change continuous IV medications to intermittent or other route

• Camouflage or pad IV and other tubing or dressings with gauze or stocking

• Provide frequent care of feeding tubes, catheters and other tubes

Alternatives for Fall Prevention

• Scheduled toileting individualized to patient’s needs and pattern (may also eliminate the need for an indwelling urinary catheter)

• Proper lighting• Complete fall risk assessment, including gait, use of

assistive devices, toileting problems• Early involvement of PT and OT to assist with

assessment and formulation of mobilization plan• Establish “safe periods” in which restraints are

removed and the patient is monitored closely during the night

Facilitate the Patient’s Environment

• Use visual clues such as schedules, calendars and clocks

• Labels on floor and doors to help orient patients and prevent wandering in restricted areas

• Use a wedge cushion to prevent a patient from sliding out of a wheelchair

• Non-skid floors or non-skid mats around beds and other areas

• Use non-glare lighting and nightlights to provide clear visual recognition

Diversion

• Take the patient’s mind off the situation by diverting his/her attention to something else such as:

• Watching television• Listening to music• Talking on the phone• Reading books or magazines

Least Restrictive Restraint

• When alternative methods fail to keep the patient and others safe, use the LEAST RESTRICTIVE RESTRAINT possible.

Restraint Use

• Each time a restraint is used it must be reported to your supervisor or clinical leadership as soon as possible.

• Each time a restraint is used it must be documented on the patient’s chart.

• Each restraint use must have a physician’s order

Important to Remember

• Always remember that restraints/seclusion are prohibited when used as a means of “coercion, discipline, convenience, or retaliation by staff’ in any setting

CMS, 12/2006