|
heart failure |
HTN |
↓ cardiac function |
↓ respiratory function |
hyperthermia, hypothermia |
hyperglycemia hypoglycemia |
fluid electrolytes imbalances |
↓ renal function |
toxic substances |
trauma |
anaemias |
hypoxia |
medications |
malnutrition |
emotional stress |
Autonomy, Beneficence and Abuse
•Mrs smith, aged 75, has been admitted to your unit for rehabilitation.
•She had a left total hip replacement two weeks ago following a fall in her bathroom
at home.
•She has a known history of heart failure, hypertension and osteoporosis.
•Before admission to hospital she was prescribed
• Lasix 20 mg od,
• Captopril 25 mg od,
• Calcium Sandoz 1000mg od
• Slow K one tab od.
•Prior to her admission she lived alone and was independent in her home,
• with the aid of a walking stick.
•a. You are aware that after a fall the older adult may be reluctant to mobilize owing to fear of falling again.
•You become concerned that she is not mobilizing, as she should.
•She tells you that when she goes to physiotherapy the staff doesn’t seem particularly interested and that she finds ‘the exercises too tiring, and she will be more mobile in a week or so’.
Discuss the competing values of autonomy and beneficence
in the current situation and for the weeks ahead (5).
•In current situation I would acknowledge Mrs Smith’s feeling of fear of mobilizing.
•The value of autonomy gives the client the option of self-determination or independence.
•Mrs Smith should have a choice of feelings & options respected.
•According to the beneficence, the staff has an obligation to provide a duty of care that incorporates the intention of doing what is good for the client.
•Therefore, the staff reassures her that the physiotherapist is needed for her rehabilitation, and that staff continues to encourage her to talk about her fears.
•Subsequently, in discussion with this gentleman you discover that the fall was suffered when he was pushed by his daughter, who is his primary caregiver, during an argument.
Outline factors that place the older adult at risk of abuse. (4)
•physical
•(slapping to severe beatings and restraining with ropes or chain).
•emotional or psychological
•(name calling to intimidating, threatening).
•neglect
•(withholding appropriate attention to intentionally failing to meet the needs of elderly)
•sexual
•(sexual exhibition to rape).
•financial
•(misuse of an elder’s funds to embezzlement)
•Predisposing factor:
•stressed caregiver- alcohol, drug dependency, cultural behavior, elderly migrants, learnt behaviors.
•
Discuss what you will do in this situation (6)
•education to daughter.
•explore cause of unexplained injuries
•assess relationships between pt and daughter.
•assist pt and primary caregiver in finding resources to help caregiver
•explain legal rights and options available to abused client
•report all suspected or actual abuse to official agency
Falls
•There are a number of intrinsic and extrinsic factors that predispose the older adult to falls.
•With reference to Mrs Smith under the following headings list the actual and potential risk factors for Mrs Smith.
Intrinsic
•1. age related change (actual)
•75 years old
•cardiovascular respiratory changes
•2. Medication (actual)
•drowsiness, dizziness,
•orthostatic hypotension, incontinence
•3. disease related symptoms (actual)
•weakness, fatigue, osteoporosis,
•ataxia, mood disturbance, confusion
•4. improper use of mobility aids (potential)
•5. unsafe clothing (potential)
•
Extrinsic
•1. environmental hazards
•2. caregiver related factors
•
Intrinsic
1. Age related changes:
•reduced visual capacity.
•cardiovascular respiratory changes
•problems differentiating shades of the same color
•cataracts
•poor vision at night and dimly lit areas
•less foot and toe lift during stepping
•altered center of gravity leading to balance lost more easily
•urinary frequency.
•2. Improper use of mobility aids
•using canes, walkers, wheel chairs without being prescribed
•properly fitted or instructed in safe use
•not using brakes during transfers.
•3. Medications:
•Drowsiness, dizziness
•orthostatic hypotension, incontinence
•4. Unsafe clothing:
•Poor fitting shoes and socks
•Long lobes and pant legs
•5. Disease related symptoms:
•Orthostatic hypotension, Incontinence, Dizziness, Reduced cerebral blood flow, Edema, Weakness, Fatigue, Osteoporosis,
•Paralyze, Ataxia, Mood disturbance,
•Confusion
Extrinsic
•1. Environment hazards:
•Wet floor (surfaces), Wax floor,
•Object on floor, Poor lightening
•2. Care giver related factors:
•Improper use of restraint,
•Delay in respond to requests,
•Unsafe practice,
•Poor supervision of problem behavior.
•2. You are caring for Mr. Parks a 79 year old Maori man who has been admitted to your ward following a fall at home.
a. Outline reasons why falls are a major concern for the older adult. (5)
•psychological effects
–fear of falling again
–loss of confidence
–increased dependency
–social isolation
•economic impact
–hospitalization or long-term placement may be required.
c. Outline the nursing interventions you might implement while Mr Parks is in your care to prevent further falls (5)
•Access for potential hazards.
•Create a safe environment.
maintain bed low position, locked. use bright light.
have a call bell within reach.
•Utilise the safety devices
such as hip protector.
•Monitor person’s intake of food, fluid, medications.
Dehydration, the side effects of drug.
•Plan intervention to reduce specific risks.
routine toileting pt’s on schedule before bed.
Osteoporosis
Hip fracture
•c. Given Mrs Smith’s history of osteoporosis and hip fracture you are aware of the need for thorough subjective and objective assessment of her musculoskeletal system as part of the functional assessment.
•ca. Brief describes the expected changes with ageing to the musculoskeletal system.
↓muscle mass and strength
bone demineralization (more women)
shortening of trunk
as result of intervetebral space narrowing. (postural change)
•↓ joint mobility
•↓ range of joint motion (lifestyle affects muscloskeletal changes)
•enhanced bony prominences (loss of subcutaneous fat)
•cb. Using the following headings outline the subjective and objective data that you might elicit from Mrs Smith as part of the assessment process (10).
•Joints
•family history?
•pain (location, quality, onset, timing, relieving factor)
•stiffness, swelling, heat, redness.
•limitation of movement
•inspect size and color of skin (red, heat, hot).
•palpate each joint, tender, temperature area of joint capsule
•Assess ROM through an passive ROM
•Muscles
•pains or cramps muscle ache with rest? or with fever?
•weakness (duration, location)
•muscle size: atrophy
•muscle strength: should be equal bilaterally
•muscle test: resist a opposite force
• Functional Assessment
•joint and muscle problem create limitation to perform ADLs.
•bathing, dressing, toileting, grooming, eating, mobilizing, communicating.
•instruct pt to /walk with shoes on / climb up stairs? / rise up from chair / rise up from lying in bed / pick up object from floor.
d. outline four aims in the treatment of osteoporosis (2).
•Deficit knowledge
about the osteoporotic process, and treatment regime.
•Acute pain
related to fracture and muscle spasm.
•Risk for constipation
related to immobility
•Risk for injury (additional fractures)
related to osteoporosis.
e. For the medications listed below provide the drug classification (Beta blocker) and the mode of action (4).
•Captopril ACE inhibitor,
•Angiotensin-converting enzyme inhibitor,
•inhibits converting angiotensin I to angiotens II.
•by blocking the re-absorption of sodium and water which lowers BP.
•Lasix Loop diuretic,
•at the level of loop of Henle of promoting excretion of Na, H2O.
Rheumatoid Arthritis
•5. Mr S Tiff is a 60 year old man, diagnosed five years ago, with severe rheumatoid arthritis.
•Initially the arthritis affected his hips but after several years his shoulders were affected.
•He walks very slowly with much effort.
•He misses his nature walks, and bike rides.
•In the past few months Mr S Tiff has been unable to fully straighten his fingers, which makes grasping objects difficult.
•This decreased range of movement makes daily activities difficult, and the recent onset of pain has meant that he is on medical leave from work (where he is a technical writer – using computers).
•Mr. S Tiff has also been affected by the recent death of his wife, Mary.
The principle of rehabilitation
•Control the underlying disease or impairment
•Develop functional abilities
•Prevent secondary disability
•Preserve the dignity of the individual
Functional (ADL’s), autonomy (self-esteem), integration (peer/social)
Define and Identify
Chronic inflammatory degenerative disorder, effecting the connective tissue,
mainly affecting peripheral joints. cause unknown
•red hot burning pain especially in the AM.
↑WBC further aggravate inflammatory process.
•↓mobility; gait instability, joint swelling, stiffness.
•↓self esteem can occur as depression.
•weakness, fatigue
c. Choose two of the clinical manifestations you have identified and discuss the nursing interventions that would be appropriate to support his rehabilitation. (8).
Pain related to inflammation
•Review of drug regimen.
(NSAID: naproxen, ibuprofen, diclofenac)
•Teach client about alternative pain remedies
(gentle massage, breathing / relaxation)
•Encourage pt to talk of feelings about pain
Such as pain scale.
•Educate pt about the effect of weight on joint and its role
in pain aggregation.
•Work simplification and time management
to reduce pain.
↓ mobility related to joint stiffness
•Assist with transfer techniques and the use of mobility aids.
To promote independence.
•Reposition frequently, supply the pillow
To prevent limit joint deformity.
•Encourage pt about not making quick movement but to get up slowly
To prevent unnecessary movement.
•Educate pt to take regular walks or low impact for exercise
To increase joint motion, muscle strength. (swimming, ROM, aerobic).
d. While assisting Mr S Tiff with his hygiene cares he becomes tearful and remarks “why bother with me I am a cripple and I am going to die like my wife eventually anyway?”
•How should you as the nurse respond?
Pt’s response
Acknowledge pt feeling.
Reassure him of fact that nurse can help him.
Listen to pt and let him know its ok to cry.
Encourage pt to think about positive things he has to look forward to.
Inform other staff concerned of pt’s emotional status as pt might benefit from medication such as anti-depressive.
P V D
6. a. Identify the assessment findings are you likely to see in a client
who is admitted to hospital because of leg pain or cramps? (8)
•Objective
•inspect legs for color, postural color of change.
•venous pattern, check for edema, varicose vein: compression test.
•size of swelling, atrophy, measure calves.
•both legs should be equal bilaterally without swelling, otherwise, DVT?.
•any lesions and ulcers, limb movement limits
•perfusion, nail of condition, ↓ hair to the legs.
•palpate for temperature of feet and legs (warm).
•palpate peripheral arteries in both legs:
femoral, popliteal, dorsalis pedis and posterior tibial,
which occurs heart failure and hepatic cirrhosis.
Subjective data
•Pains cramps: rest pain at night, intermittent claudication. family history.
•Swelling, any accident or previous operation.
•Lymph node enlargement.
•Medication.
•Hypertension, heart problem, cardiac history, chest pain, SOB, Squeezing.
•b. Briefly identify how the ageing process may affect your findings
when examining an older adult’s peripheral vascular and lymphatic systems? (2)
•Enlargement of the intramuscular calf veins
•Fewer lymph nodes & ↓ in size of remaining nodes
•DP & PTpulses may become more difficult to find.
•Tropic changes associated arterial insufficiency
•(thin, shiny skin, thick-ridged nails, loss of hair on lower legs)
•c. Outline the information you would give a client with chronic arterial insufficiency
to promote maximum function? (6)
•Location:
deep muscle pain, usually in calk.
but maybe lower leg or dorsal of foot.
•Character:
intermittent claudication (pain with walking),
feel like ‘cramp’, numbness & tingling,
feeling of cold.
•Chronic pain.
gradual onset following exertion.
•Claudication distance
is specific number of blocks.
•Relieving factor:
lower with feet on the floor (standing, dangling)
•Associated symptoms:
cool pale skin.
Heart Failure and changing for ageing
Heart failure: clinical manifestations
•a. left ventricular heart failure:
•inability of the left ventricle to pump the blood to body tissues
•exertional dyspnea,
•orthopnea,
•paroxysmal nocturnal dyspnea,
•cough,
•blood-tinged sputum,
•cyanosis (central),
•elevation in pulmonary capillary wedge pressure.
•b. right ventricular heart failure:
•inability of the right ventricle to pump to the pulmonary circulation.
•fatigue,
•dependent edema,
•distention of the jugular veins,
•liver engorgement,
•ascites,
•anorexia and complaints of GI distress,
•cyanosis (peripheral),
•elevation in peripheral venous pressure.
•Provide examples of secondary changes that may occur following the primary changes of ageing (6).
•For example: secondary changes of vertebral disc shrinkage may include chronic pain, immobility, and muscle atrophy.
Loss of arterial compliance |
↓ vital capacity |
↓ renal blood flow and filtration |
↑arteriosclerosis, |
↑susceptibility to lung infection, |
↓ urine formation, |
↑blood pressure, |
Pneumonia, Aspiration |
Urine stasis, ↑UTI, |
↑heart disease |
↓ capacity for physical activity. |
↓ drug excretion |
|
|
↑toxicity. |
CVA
•Your patient Mrs Black has been admitted to your unit for rehabilitation from an acute medical ward following CVA three weeks ago.
•Define: (3 MARKS)
•a. Cerebrovascular Accident (CVA) :
a neurological deficit that lasts over 24 hours.
•b. Transient Ischaemic Attack (TIA) :
a brief episode of neurological deficit that resolves without any residual effect.
•c. Reversible Ischaemic Neurological Deficit (RIND) :
deficit persist beyond 24 hours but resolves with no deficit.
Identify 8 risk factors that may place Mrs Black at risk for a CVA. (4 MARKS)
•Non modifiable
age, sex, race, family history.
•Modifiable
smoking,alcohol, sedentary life style,
oral contraceptive use, elevated serum cholesterol and triglyceride.
obesity, hypertension, DM, heart disease.
•7. Mr Prentice has been admitted to your ward following a CVA. The result of this CVA is that he now experiences symptoms associated with occlusion of the middle cerebral artery.
•a. List 5 clinical manifestations that you might expect him to exhibit as a result of this. (5)
contralateral hemiparesis (leg) or hemiplegia (arm) deficit
contralateral sensory impairement
unilateral neglect or inattentiveness
aphasia
homonymous hemianopia
•b. Choose two of the clinical manifestations you have identified and discuss the nursing interventions that would be appropriate to support his recovery. (4, 4)
aphasia
encourage pt to speak, eye contact.
allow pt time for response.
establish a non hurried atmosphere.
picture board or book
may be necessary to communicate needs
inform family in planning and implementing all strategies.
hemianopia
approach from the side of intact vision.
position pt the room
so that intact visual field faces the door if possible.
teach pt to move head side to side
to compensate for diminished visual fields.
place objects for self care
within pt’s intact visual field.
use eye patch to prevent diplopia.
•Reading the patient’s medical record you note that as a result of the CVA she experiences Vertebrobasilar Artery Syndrome.
List 5 clinical manifestations that you might expect her to exhibit as a result of this.
(5 MARKS)
Ataxia and clumsiness (uncoordinated muscle movement)
Dysphagia (swallow impairment),
Dysarthria (communication, slurred speech).
Dizziness and nystagmus (involuntary oscillation of the eye ball)
Bilateral motor and sensory deficit.
Facial weakness and numbness.
Nausea and vomiting
•Choose two of the clinical manifestations you have identified and discuss the nursing interventions that would be appropriate to support her rehabilitation. (10 MARKS)
Dysphagia
Have pt sit upright or sitting in chair
for meals.
Oral care before meal
to stimulate saliva, after meal to check hygiene.
Give thick shake, food with texture, cold foods.
Keep fluid intake
until drinking is sufficient.
Monitor pt’s weight
and notify dietitian as needed.
Ataxia
Protect from falls.
Access ADL function
Call bell within reach.
Skin care explain
Allow time, explain actions.
Urinary incontinence
•Non-voluntary voiding when the pressure in the bladder is greater than the resistance of the urethra.
•urinary leakage that is objectively demonstrable and presents a social or hygienic problem.
•C. another consequence of Mr prectice’s CVA is that he now experiences urge incontinence.
•Involuntary passage of urine after a strong sense of urgency to void.
•You institute a bladder-retraining programme.
•What is the purpose of such a programme?
•To restore normal pattern of voiding by inhibiting or stimulating.
•Strengthening the muscle of bladder.
Outline the nursing interventions you would implement
to achieve the goals of a bladder retraining.
•Instruct pt to take regular pelvic floor exercise.
•Formulate voiding & toileting schedule.
Interval between voiding is short in the initial stage.
Encourage pt not voiding until the specific voiding time.
Provide barrier free environment for pt to access the toilet.
•Apply a fluid intake chart,
•Apply incontinence pads.
•Provide privacy each void.
•
Incontinence present
•physiologic: predisposition to impaired skin integrity, impaired skin hygiene, and a small hyperactive bladder.
•social: withdrawal from people and activities, and the need for nursing care.
•emotional: the embarrassment and shame associated with the problem can lead to depression, self-neglect, low self-regard, and reclusion.
•financial: there can be considerable cost both for the incontinent person and for the health care system in purchasing equipment required to manage the problem.
•
What factors are related to the risk of urinary incontinence increasing with age?
•meds
•mobility issue
•pathophiology (tumor, UTI)
•impair cognition
•dehydration
•decrease kidney capacity
•decrease nephrons
•decrease sensation related to CVA
•loss of muscle tone
Define the following types of incontinence.
•stress: leakage of small volumes of urine caused by sudden increase
in intraabdominal pressure. eg. coughing, sneezing.
•urge: involuntary passage of urine after a strong sense of urgency to void
•reflex: involuntary loss of urine occurring at somewhat predictable intervals:
large or small volume
•overflow: voluntary or involuntary loss of a small amount urine
from an overdistended bladder
•functional: involuntary, unpredictable passage of urine in a pt
with intact urinary and nervous system.
When assessing your pt for urinary incontinence what data will you need to collect?
•health history:
symptoms associated with dysfunction,
perception of micturition,
functional toileting abilities.
•fluid balance record and voiding patterns.
Times, amounts.
•episodes of incontinence and associated activity
coughing sneezing, lifting, H2O, meds,
•related cognitive functioning.
perception of need to void, ability to control urination
•reviews the results of the diagnostic studies
urinalysis.
Identify 8 NI with urinary incontinence.
•complete a bladder log.
including frequency of urine,
patterns of incontinence
volume of fluid consumed.
•establish a toileting schedule for pt.
toilet pt every 2 hourly
•apply barrier cream.
•dry perineal area after each void
to maintain skin integrity
•an adequate fluid intake.
•remove environmental barriers to toilet.
Uncluttered, light bright in hallways.
•call bell in place.
•change pt’s pad regularly.
|