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- 1. Dee Tucker RN, MS, GCNS-BC Nursing Service An Overall Assessment Tool of Older Adults SPICES
- 4. SPICES Interventions Assessment S leep Disorders P roblems with Eating/Feeding, P ain I ncontinence C ognition E vidence of Falls, Mobility problems S kin Breakdown
- 5. SPICES Interventions Assessment S leep Disorders Restless or wake-sleep cycle disturbance Sleep protocol Evaluate for cause & treat (pain, delirium, etc)
- 6. SPICES Interventions Assessment P roblems with Eating/ Feeding, P ain % food eaten for each meal last 24hr PO fluid intake amount UOP Wt if daily LBM 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 hrs If no BM in 3 days
- 7. SPICES Interventions Assessment I ncontinence Any episode Foley catheter Begin Toileting schedule Evaluate for UTI DC’ing when C ognition Any change in LOC, attentiveness, memory, Evaluate for cause (pain, delirium, etc
- 8. SPICES Interventions Assessment E vidence of Falls, Mobility problems Orthostatic BP & pulse Function & mobility as observed in last 24 hrs Falls- circumstances If greater than 20 point drop in systolic If below baseline, or declining If occur S kin Breakdown Any change With risk or actual impairment
- 10. Atypical Disease Presentation in Older Adults Dee Tucker, MS, RN, GCNS-BC Nursing Administration
- 12. Signs and Symptoms Learn baseline prior to illness Remember aging changes Recognize presenting symptoms
- 15. Presenting Symptoms Signs and symptoms in older patients are generalized and can represent any number of medical situations.
- 19. Respiratory Infection BLUE represents amount of air inhaled RED represents lungs PINK represents the diaphragm
- 30. Delirium: Can You Recognize Acute Confusion? Dee Tucker, MS, RN, GCNS-BC Nursing Administration
- 53. Depression
- 68. Nutrition and Hydration in the Older Adult
- 93. Discharge Planning Collaboration is key
Notas del editor
- Normal aging brings about inevitable and irreversible changes. These normal aging changes are partially responsible for the increased risk of developing health-related problems within the elderly population. Prevalent problems experienced by older adults include: Normal aging brings about inevitable and irreversible changes. These normal aging changes are partially responsible for the increased risk of developing health-related problems within the elderly population. Prevalent problems experienced by older adults include:
- Using consistent review of high risk areas decreases likelihood of missing things
- Need to know baseline prior to illness
- Nl aging: Older adults usually have more difficult time falling asleep, have impaired sleep maintenance because of arousals, and more difficulty in returning to sleep once they are awakened during night There is a decrease in stage 3 or 4 “deep sleep” and increase in stage 1 or “light sleep” Older adults are more likely to awaken because of environmental factors such as noise or physiological factors such as pain or nocturia Sleep: what is their baseline sleep apnea- do they snore; , restless leg syndrome, depression, delirium Do they use sleep aid at home?? Has it been ordered sleep protocol
- Nl aging changes: Early satiation, when miss a meal- don’t play catch up Oral health / care Loss of taste buds, sense smell, thirst sensors Affected by chronic issues as pain, PD, COPD, depression as well as medications and constipation With increased frailty and deconditioning, loss of function follows a predictable pattern, with the ability to feed oneself the last activity of daily living (ADL) to be lost Hospital acquired malnutrition: patient may be kept on downgraded diet when the original problem has resolved. If less than 50% need further intervention/nutrition consult Keeping accurate track of I/Os extremely important as older adults at increased risk for dehydration If intake < 1500 ccs need to intervene
- New onset incontinence= infection Foley cath only reason for having: Foley Catheters are indicated for: ____Urinary Tract Obstruction ____Gross Hematuria with clots ____Neurogenic bladder with retention ____Urologic surgery or studies ____Sacral decubiti Stage 3-4 ____Hospice, Comfort or Palliative Care Remove ASAP- risk for CAUTI increases 5% each day with dramatic rise at 4 days Cognition: affected by lack of sleep, pain, medications, anxiety Screen as snapshot and to identify if need further evaluation Cannot screen for dementia or depression if delirium present; if have undertx or untx depression can not clearly eval for dementia
- Ortho can be early indicator of higher fall risk, dehydration Often overstate their abilities; if can do task but takes long time or barely able – very close to losing ability Verify with family or facilities Intervention- for pt or work with family- consult rehab Pressure ulcers are associated with complications including cellulitis, osteomyelitis, sepsis, increased length of stay, financial and emotional costs Easier to prevent than heal; “Never event” for CMS
- Nurses rely on signs and symptoms from patients to direct their care. Older adults respond differently to illness, treatments and interventions due to : changes in organ systems Progressive loss of reserve Interaction of multiple conditions with the acute illness
- Treatment and interventions will be more accurate Earlier intervention prevents progression to more serious situation Prevent common complications and issues for older patients We will look at changes is S&S with older adults in general and then specifically with cardiac and infections you are most likely to see in the hospital.
- Must compare to normal prior to the illness Differentiate between normal aging and illness in signs and symptoms Set of symptoms see in older adults that should raise red flags
- Older adults have the most variability than any other age group. Perception of older adult may not reflect true abilities situation; verify with family, caregivers, facility staff, etc Frail older adults are most likely to have atypical presentation of illness- their reserves are stressed to the max- Add to this normal aging-
- Symptoms reported become less specific- that is what the older adults is experiencing- usually due to aging changes indifferent organ systems. Discomfort may become a generalized area rather than a limited spot which more clearly defines which organs are involved The different components to respond are muted or dampened with injury or illness thus symptoms reported and signs we look for will be less Ex: immune system, T cells The sensors and alarms systems in body take longer to marshal a response thus pt will have been ill longer before it is recognized- allows greater load of bacteria or virus, or illness process will be further along This leads us to how do problems present -
- Cognition: less sharp in processing, impaired thinking, all the way to “confusion” Mobility: older adults presenting with New onset falls, weakness impairing daily activities needs to be evaluated for an underlying problem- not just checked for apparent physical injury Decreased appetite, lethargy, self care can be present with any number of medically treatable conditions Let’s look at infections and cardiac issues you will come in contact with in hospital.
- These issues can be community acquired and result in hospitalization or be acquired during a hospital stay. Looking at the symptoms the patient may be reporting, then the signs you would assess for, and then any labs you might anticipate abnormals in with a younger pt
- Not all older pt have abd discomfort- they may attribute to bowl issues Decline in sense of smell- they might not have noted this at home Pt may not have reported because they assume incontinence is just part of getting older Thinking- here need baseline and comparison by someone other than pt Temp of 100 can be fever if base temp 97 Blood WBC can be nl – by time see left shift in differential have serious infection; may have dehydration in lab due to decrease intake with incontinence and kidney unable to conserve water (aging); Less T cells to respond and less aggressive and slower to present- temp remains lower thus does not provide help in killing off bacteria/virus as temp at 101 does
- Not all older pt have abd discomfort- they may attribute to bowl issues Decline in sense of smell- they might not have noted this at home Pt may not have reported because they assume incontinence is just part of getting older Thinking- here need baseline and comparison by someone other than pt Temp of 100 can be fever if base temp 97 Blood WBC can be nl – by time see left shift in differential have serious infection; may have dehydration in lab due to decrease intake with incontinence and kidney unable to conserve water (aging); Less T cells to respond and less aggressive and slower to present- temp remains lower thus does not provide help in killing off bacteria/virus as temp at 101 does
- Dehydration makes lungs dry- thus no mucus moving- no cough; May not report this is their nl lifestyle does not have any exertion Nl resp rate 14-16 Falls- no clear explanation but depleted reserves Need baseline and a someone to compare- not sure if due to decreased O2 or stressed reserves chest Xray may not be definitive until hydrated
- Dehydration makes lungs dry- thus no mucus moving- no cough; May not report this is their nl lifestyle does not have any exertion Nl resp rate 14-16 Falls- no clear explanation but depleted reserves Need baseline and a someone to compare- not sure if due to decreased O2 or stressed reserves chest Xray may not be definitive until hydrated
- Depending on site: May have peripheral neuropathy, some states pain reception declines as age comes from immune systems response with WBC and increased blood flow to area- all decline with aging Lab: same as with other infections
- These are fairly common cardiovascular issues older adults can present with or acquire while hospitalized. We can cause heart failure with too rapid infusion of IV fluids Stress of hospitalization Being too immobile can result in DVT which can lead to PE
- Lifestyle may include little exertion so would not c/o this May already sleep on elevated pillows or recliner for other reasons Rales may be masked by co-existing lung disease Rales can be caused by reclining posture- basilar rales is a sign of ventricular failure Need baseline and someone to compare Not too different but sloe to show elevations
- Pain often isolated to throat, or shoulder or abdomen, or “silent MI” Dyspnea is most common symptom; need baseline, someone to compare; confusion with decreased O2 to brain Slow to elevate; may not elevate high enough to confirm in some malnourished patients
- 50% of pts with proximal DVT will have asymptomatic PE presentation RARELY hempoptysis Leg edema, discomfort, erythema, warmth Positive D dimer also found in recent surgery, malignancy, trauma, active CV disease ABG can be normal or reveal resp alkalosis due to hyperventilation You can see how the symptoms are vague, overlapping, - not clear cut but are not normal signs for older patients. Try this quick case with an older patient
- Progressive issues with strength, mobility over short period of time: had falls Some baseline
- The report you receive does not have any major definitive problems. Let’s look at the symptoms, signs and lab
- Symptoms indicate a major change that has not improved Temp and resp that could be important – need to know baseline if possible; but know that 20 is higher than expected; temp could indicate a fever From what we have looked at today; could this be heart failure, MI, UTI? Or a combination of these and others such as depression.
- Recognize the significance of atypical symptoms / presentations and pursue possible causes- may be more than one medical issue involved By recognizing that older adults can have atypical presentations, Nurses can ensure quality care and positive outcomes.
- Older patients are at high risk for complication of delirium which can require increased nsg time and staff as well as increased LOS, NH placement, morbidity, mortality, fall risk, infection, aspiration, malnutrition- dehydration Delirium is a frequent complication of illness and hospitalization for older adults- up to 80 %, and up to 89% of pts with delirium. But it’s effects can be largely or completely reversed when cause is identified and treated Nurses are the primary professionals to detect delirium in patients and prevent these complications. We are going to look at specifics of delirium, how to assess and prevent this and appropriate interventions when it occurs.
- Delirium is a disorder of multiple factors 1. normal aging, there is less physiological reserve with the brain being more susceptible; the balance is more fragile 2. changes in environment- such as hospitalization, ICU stay -74% of all cases occur in critical care areas), terms such as ICU psychosis imply an expected outcome; or move to NH 3. Leading cause of delirium is Adverse drug reactions- always think drugs 4. Malnutrition ( can have on admission or may cause during stay), anything that alters cerebral blood flow ( CVA, head injury, blood loss); decreased O to brain ( shock, heart Failure, anemia); fluid, lyte imbalance- dehydration, hypo or hyper natremia); vit deficiency, infections, metabolic disorders( DM, hypercalcemia, liver failure); Withdrawal- alcohol, narcotics, barbiturates, SSRIs Under treated pain 5. Surgery-up to 60% of older surgical pts have delirium with hip fx,vascualr surgery and elective joints have highest incidence, use of versed increases risk ( hyperactive most commonly seen) as does epidural anesthesia and longer duration of anesthesia Can begin with transient restlessness in the immediate post op period- leads us to assessment for delirium but there are 3 types of delirium presentation
- agitated, aggressive, hallucinations, constant motion, non-purposeful-repetitive movements, verbally and physically aggressive, hallucinations Clouded inattention- requires strong stimulation to arouse; withdrawn, apathy, inattention; Often unrecognized- poorer overall prognosis- most common in older adults fluctuates unpredictably Behaviors you see demonstrated vary somewhat depending on type of delirium; Generally see trying to escape the environment, removing medical equipment, maybe combative, non purposeful repetitive movements, moaning- calling out, resistive to care Delirium develops over hours- days Lasts days to months First symptom is often anxiety ATTENTION night staff- 1-3 days prior to full blown delirium see change in sleep-wake cycle or disturbed sleep, restless, anxious, irritable, loss of mental clarity or some disorientation, change in ability to shift or change focus
- Watch labs, record I&O and food intake; encourage 1500 ml as minimum; check orthostatic BP OOB, eat in chair, ambulate 3x/day; obtain PT referral as needed Clocks, calendars, white boards; Therapeutic Rec for engagement orient and engage Begin sleep protocol ( warm drink, back rub, oral care and warm washcloth- turn on music, turn down lights, consolidate staff trips, decrease noise in hallway Glasses, hearing aids- working battery, wears glasses, telephone aids from hospital operator Assessment requires a way that different nurses can compare their findings as well as comparing a patient’s behaviors over time.
- Prior to illness- caregiver, facility staff, family, friends Baseline Memory- short term, and processing , completing tasks Alertness is basic arousal, attentiveness = thoughtful engagement with environment; select what want out of environment, sustain focus to process information- without this have safety risk Function- independent, or requires assistance Mobility Now need to compare to current status-
- Is this their baseline mental status or has pt had any fluctuations in mental status in past 24 hrs as evidenced by fluctuation on sedation scale, GCS, or previous delirium assessment
- First establish that pt can follow a simple “yes” “no” – such as nod head, squeeze hand- if can do this then conclude there is the basic ability to understand directions Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? 2.Letters: Say to patient “ I am going to read you a series of 10 letters. Whenever you hear the letter A, indicate by squeezing my hand” Then read letters in normal tone Score this a incorrect if they squeeze on any letter other than A, or do not squeeze when you say A OR can use pictures- most commonly used in ICUs or CCUs . Show 5 pictures 3 sec each. Then tell them going to show them more pictures and to squeeze or indicate when they see a picture from the first set
- First establish that pt can follow a simple “yes” “no” – such as nod head, squeeze hand- if can do this then conclude there is the basic ability to understand directions Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? 2.Letters: Say to patient “ I am going to read you a series of 10 letters. Whenever you hear the letter A, indicate by squeezing my hand” Then read letters in normal tone Score this a incorrect if they squeeze on any letter other than A, or do not squeeze when you say A OR can use pictures- most commonly used in ICUs or CCUs . Show 5 pictures 3 sec each. Then tell them going to show them more pictures and to squeeze or indicate when they see a picture from the first set
- If pt is not positive on BOTH 1 and 2 then stop. Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Use these questions Command Say to pt “Hold up this many fingers ( hold up 2 fingers in front of pt. “Now do same thing with the other hand ( not repeating the number of fingers) This helps affirm that pt did not randomly guess correctly the 4 questions
- Score 1&2 and either 3 or 4 = for delirium. Alert ( normal) Vigilant ( hyperalert) Stupor (difficult to arouse) Coma (unarousable)
- Look at handout / worksheet in folder- looks very busy because have put all the info on one page. Do not be overwhelmed- just 4 questions CAM was designed to be scored based on observations made during brief but formal cognitive testing. There is a false positive rate of 10%. The tool identifies the presence or absence of delirium but does not assess the severity of the condition Now that you have a tool, How frequently do you assess for delirium?
- On admission to get current status Daily so can compare if changes When see potential subtle changes in behavior to determine what your actions need to be In order for this info to be useful, it must be documented for other staff to com pare to.
- To compare need to record baseline prior to illness, the score from the CAM and specific behaviors noted
- Collaborate with MDs re: possible untreated infection( often UTI or resp), lab work,; MDs and pharmacists for a med review and evaluate for interactions ( lasix, lanoxin, theophyllin)
- Family Have them bring familiar items ( pictures, play favorite music; determine if they are a source of support-ask them to stay; educate family delirium is a temporary condition that will improve with tx It is reasonable and appropriate to ask family to help- similar to a parent staying with a frightened hospitalized child !
- Remove unnecessary equipment Avoid physical and chemical restraints; foley catheters and IV are one point restraints Only 4 reasons for foley cath: oveflow with obstruction, fl balance is critical, short term for stage 3 or 4 ulcer, severely impaired or terminally ill 80% hosp acquired UTI from foley and 40% of ALL UTI due to foleys Staff continuity- approach in calm manner and voice; use simple terms, avoid sudden movements Calm approach / reassure
- Proactively address- nutrition, hydration, skin breakdown, blood clots ( immobility), mobility and deconditioning / loss of function, use sensory aids,
- Baseline- essential On adm and daily: miss the hypoactive ones- we have hours to days to pick up on it building Prevention easier than treating It is obvious when you look the type and length of contact we have with our patients that nurses were found to be superior when compared to physicians in detecting delirium. You are the best group positioned to prevent the medical complications for the pts and therefore the increased stress on nsg staff.
- Under diagnosed because symptoms may be confused with the effects of illness or medications. These could be our frequent fliers who complain of multiple physical ailments. Depression can amplify these. Depression is NOT a normal part of aging.
- Explaining depression to someone who has not experienced it is hard. For those of you who experience severe PMS…..imagine feeling like that ALL THE TIME.
- Usually a decrease in appetite/ daytime sleepiness and fatigue, insomnia, awakenings./memory loss, difficulty concentrating, abnormal thoughts, excessive guilt, thoughts of death and suicide. Different people can present with different symptoms. Some are overtly sad. Others…just angry. OR Apathy...they just don’t care anymore.
- Overlapping symptoms: Fatigue, psychomotor slowing, loss of appetite, sleep disturbances, etc. Often in clinical setting physician doesn’t have time to address anything except physical complaints. Because of the Stigma associated with mental illness many patients will deny feelings of depression.
- Women higher prevalence, but white males over the age of 80 have higher rates of suicide. It may not be that women are MORE depressed. It may be the way they show it. Men are less likely to present with overt sadness or crying the way women do. Men more likely to present with anger, irritability, emotional withdrawl or substance abuse. I don’t think older men are any less depressed it is just the way they show it.
- I am a firm believer that what it boils down to is a chemical imbalance of the neurotransmitters that control mood. serotonin, dopamine and norepinephrine. And there are many things that can throw these out of whack. You’ve heard people say “get over it. It’s all in your head” Well…….yeah. And you can’t just ‘Get over it’. Alcohol and drug abuse used to be considered only a symptom of underlying depression. New studies have shown that it can actually be a cause. Think about it…you’ve all seen the commercials…’here’s you brain on drugs’? What initially may produce euphoria, with continued use could alter brain chemistry causing depression.. The synapses get fried. Alcohol by definition is a depressant. So the depressed person who turns to alcohol to improve their mood is not doing themselves any favors. Heredity plays less of a role in late life onset of depression. Usually, familial depression presents earlier in life and is more chronic in nature. Medications: Illnesses:
- This makes sense. These diseases are associated with vascular ischemia. For instance, diabetics have chronic circulation issues resulting in kidney failure, blindness, amputations. It stands to reason that the cerebrovascular system is affected as well. Limiting the blood supply can cause neurobiological changes in the neurotransmitters responsible for mood.
- SSRI’s generally the first line of treatment. SNRI – Cymbalta has been associated with fatal liver disease in patients with pre-existing liver disease. DNRI – Wellbutrin less likely to be associated with wt. gain. May be effective for patients who are lethargic. Remeron – is sedating and can cause increased appetite and wt.gain in a high percentage of patients. Tricyclics – Anticholinergic effects such as dry mouth, constipation, urinary retention, tachycardia, confusion, delirium and hallucinations. Elderly particularly susceptible. Can also cause orthostatic hypotension. MAO’s – Way too many interactions.
- This is the tool we use at Piedmont. Remember this is just a screening tool. It does not diagnose. How you approach a patient with this is important. Don’t just barge into the room and say “please fill this out”. These are personal questions. Get to know your patient first. Develop a relationship. A truly depressed person may not be inclined to tell the truth. If they know you care they may be more straightforward. Ask permission to discuss the tool and then explain why it is important to be honest. Ask them to complete the first 5 questions. If they score more that one on these, ask them to answer all the questions.
- Primarily talk about malnutrition- where intake is less than your needs
- We are going to focus on hospitalized older adults: Actually med surg pts nutritional status actually tends to worsen during a hospitalization Just how important is nutrition during a hospital stay?
- LOS increases by 90% Hospital charges can be as much as 75% higher As it weaken the respiratory muscles – leads to respiratory infections Protein calorie malnutrition, type most often in these pts, results in skeletal muscle wasting- then decreased strength and falls
- Immune system is affected Also puts at higher risk for emboli If protein drops enough leads to edema in tissue or ascites, diarrhea Affects CO, hr , and BP- all should be monitored closely medications that bind to protein will then have higher levels – thus standard dose can actually be at toxic levels : think dilantin, coumadin
- You have more specifics on these in your handout so I am going to focus on the physiological factors particularly as they would affect a hospital patient
- Chronic issues such as cardiac and COPD increase the calorie requirements due to increased muscles required for basic function Medications- alter taste, absorption, appetite Last 3 items refer to normal aging changes that affect food intake Decreased lean muscle ( skeletal) and increased percent of fat When have protein calorie malnutrition- breakdown skeletal muscle then loss of strength which causes decraesed physical activity- vicious cycl Others are early satiety ( feel full with less eaten) ,overgrowth of bacteria in bowel prevents absorption of nutrients Disease/ symptoms that affect nutrition: N/V/D, anxiety, pain, fatigue, depression, SOB, neuro conditions affect chewing-swallowing Surgery- injury-burns all increase nutritional needs significantly Then add in NOSOCOMIAL causes: hospital acquired being in hospital – meals held due to tests and not replaced; long periods of NPO due to concurrent tests scheduled; diets not advanced; intake not observed; Data shows Older adults don’t “play catchup” when they miss intake and have wt loss Mismanagement/inattention: MD writes order- dietitian dev plan- nurse records intake Who’s job is it to evaluate nutritional interventions for effectiveness; take a “wait and see” attitude for improvement- this gets our older pts in trouble
- Need to know baseline so can evaluate where and what are needs, issues- goes toward the discharge plan
- Need accurate info for med calculations and determine nutritional needs Measure do not use pt/family reports
- Use calorie cts for accurate estimate of calorie and nutrient intake However- if less than 50% eaten off tray- this is a red flag- intervene; NPO for more than a few hours should also raise your concern
- Can also indicate self neglect, cognitive impairment Fluid intake is related to food intake: if not eating enough then almost sure they are not drinking adequately
- Why is this more a problem with older pts? Mortality of up to 50% if not treated Risks: Nl aging shift in body composition- have a decrease in total fluid thus less to lose before get in trouble plus kidneys become less able to concentrate urine Meds- diuretics Illnesses v/d Chronic issues- incontinence- they will restrict intake to decrease this!!!!!!!!! Being in hospital- functional problem of getting to fluids , selection
- Makes early dx difficult symptoms vague, deceptive, absent
- Look for tongue and mucus membrane dryness as well as longitudinal furrows, speech difficluties, CONFUSION or may be a decline in sharpness
- Particularly if they are symptomatic;c /o dizziness with rising very telling
- 3 types of dehydration- one easiest to recognize with labs- hypertonic ( water deficit) Na > 150, serum osmolality >300 Water and electrolyte deficiency= isotonic Hypotonic- loss of lytes greater than loss of waqter
- Symptomatic interventions- after if has occurred Easier to address hydration ad nutrition than it is to correct malnutrition and dehydration: proactive is best
- Food intake less than 50% at a meal – don’t wait, intervene; liberalize diet- better to eat something than little or nothing; nutrient dense foods NPO for multiple concurrent tests- rearrange to space them so pt can get food and fluids ; if npo for extended time be sure they have IV hydration Encourage fluid intake of 1500 ml- don’t wait until IV is out- may actually get it out sooner this way; unless medically contraindicated- chf, renal Involve pt- explain nl aging diminishes thirst “alert” and they need to consciously drink when not thirsty- studies show older pts will try when informed Company during meals- we all eat more when we have this; meals are a social event for most people; family , friends, bring favorite foods as allowed
- If feeding a patient- when have memory issues- may try mime actions sit across as though at dinner table
- Silent aspiration Look for repeated swallows to move food, thick or congested voice or coughing while eating Do not provide nutritional supplements WITH meals- use between as with med passes; these are rich and may result in diarrhea so introduce slowly: start with ¼ to ½ can a day for several days then if no change in bowel habits increase to a full can and continue like this
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- Home with no aftercare needs identified Home Health Care; Transportation needs; Financial assistance;Assisted Care/ Personal Care Homes;Nursing Homes ( 2 levels SNF/Subacute or Custodial);LTAC;Rehab facilities Hospice Care ( home or facility); Homeless Shelters; Psych Tx ( Inpatient /OP)
- Pt returned home with daughter with HH. She was to have Emergency Response System/ Lifeline and HH with increased days for Housekeeper assistance when she returned to her home in Maryland.
- Pt was drawing prison uniform with Prison ID #. Upon investigation, he had spent past 20 yrs. In Ga State prison System. With Atlanta Police assistance, his family was located in Ala. And he was placed in a Personal Care Home in Ala.
- When I talk about incontinence, I’m speaking of those individuals that have a significant problem and it has a major affect on their everyday life. For instance, my mother unconsciously crosses her legs when she sneezes so she doesn’t leak. Even though she meets Webster’s definition for incontinence, she has found a way to manage her sphincter weakness and therefore it is not bothersome to her… she does NOT meet the clinical definition of incontinence.
- Cerebral Cortex – social continence Pontine Micturition Center – automatic coordinated voiding Micturition reflex – threshold Spinal Cord Pathways – communication pathways (sympathetic, parasympathetic, pudenal) Bladder – smooth muscle contracts, norm: low pressure storage with ability to stretch Urethral Sphincter – norm: remain closed during bladder filling & to relax prior to and during voiding “ Head to Tail” assessment
- Males have 3 advantages over females in remaining continent. These things give greater urethral resistance and are less likely to allow urine to involuntarily pass from the bladder Length of urethra is greater in males Prostate gland in a man gives additional compression at the proximal urethra 2 curves of the urethra in a male So, incontinence is widely seen in females but males do have their own set of problems, usually involving the prostate.
- Prostatectomy: the sphincter is located just below the prostate. At risk of damaging the sphincter or the nerves that innervate the sphincter muscle. Pelvic Floor Relaxation Prostatectomy Sphincter Denervation ( SCI, Myelomeningocele ) Talk about the use of Urinary catheters later.
- urine loss due to inappropriate bladder contractions Characterized by frequency and/or urgency Men with enlarged prostates have urinary frequency issues. Need to be worked up by a urologist to determine the true etiology.
- CORRECT THE CAUSE! Stress – Meds: Sympathomimetic drugs increase the muscle tone in the proximal urethra (Sudafed, Ornade, Dexatrim without Caffeine) OAB - Anticholinergic Meds: raise the sensory threshold and reduce bladder irritability. But, can cause urinary retention
- Pt with dementia. The brain is not interpreting the signals from the bladder. Lack of orientation or unfamiliar surroundings… Where’s the bathroom? Physically unable to get out of bed or the chair to get to the bathroom… Orthopaedic surgery patients.
- D: Happens w/ new surroundings, narcotic use given for pain I: Irritants – Caffeine, nicotine, Nutrasweet, alcohol A: Estrogen deficiency can reduce urethral resistance as much as 33%... PINK and PLUMP P: Sedatives, narcotics, muscle relaxants, some anti-hypertensives, anitdiarrheals, antipsychotics, antidepressants, diuretics P: severe depression can reduce a person’s motivation to stay dry… DULOXETINE (not FDA approved) E: Polyuria with Diabetes R: Our ortho patients can’t get to the BR S: #1! When stool stays in the colon, it takes up space and can shift or irritate the urinary structures enough to create incontinence.
- Having a urinary catheter means the door is always open for infection Use of silver catheters (antimicrobial) D/C them ASAP Every time the closed system is opened (draining the BSB, flushing the catheter, taking a culture) microorganisms are introduced to the urinary tract Rather do in & out cath, b/c the doorway to the bladder stays closed