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Geriatric Analysis Paper Christine Demler NURS 314

2 GERIATRIC ANALYSIS PAPER Abstract

The following case study was chosen from our text book. A fictitious nursing care plan was developed in order to provide a simulation of the patients needs. The care plan consists of Assessment, Diagnoses, Planning, Implementation, and Evaluation. The nursing care plan has been developed to give the nurse direction in their patients care. In addition a policy need was determined which through its identification and development will help this professional team provide optimal treatment, care, and services to this particular home care patient and all patients in the future.

3 GERIATRIC ANALYSIS PAPER Geriatric Analysis Paper Rhonda is a ninety year old woman that has always been very active. She has always kept a positive attitude through tough times until she experienced a broken hip at which time her life took a drastic change. She was no longer able to do the things she enjoyed doing. Rhonda now requires a great deal of assistance with her activities of daily living. This paper will address the nursing goals, interventions and education required to improve Rhondas quality of life and assist in returning Rhonda to her pre-fall independence. Nursing Process Assessment A complete head to toe assessment has been performed. Rhondas vitals are stable for her age (97.3, 62, 18, 104/66). Her height is five foot even and her weight is 96 pounds. Rhonda is very frail and underweight. She does not eat well due to her lactose intolerance and her inability to stand at a stove to cook. She eats a great deal of pre-made frozen dinners. Rhonda has recently become incontinent of urine at times since the hip replacement surgery. Rhonda also experiences a great deal of constipation. Her lung sounds are clear throughout bilaterally. She is experiencing two plus pitting edema in her left lower leg and ankle. Rhonda has experienced edema since fracturing her left hip in June. Rhonda experiences difficulty when rating her pain on a scale of 0 to 10. As a nurse, I must be able to accurately rate my geriatric patients pain. A Wong-Baker FACES Pain Rating Scale is used. When using a Wong-Baker FACES Pain Rating Scale the nurse asks the person to choose the face that best describes how much pain she/he has (Partners Against Pain, 2012). Rhonda rates her pain an 8 Hurts Whole Lot (Partners Against Pain, 2012). A Braden Risk Assessment was performed (Braden &

4 GERIATRIC ANALYSIS PAPER Bergstrom, 1988). Rhonda experiences Stage III pressure ulceration on her coccyx and Stage II pressure ulcerations on both of her heels. A Fall Prevention Home Assessment has been performed, and she is considered a fall risk (Fall Prevention Task Force, Unknown). Rhonda ambulates with a walker when she remembers to do so. She does not enjoy using the walker. Rhonda does not have her home setup for a disabled individual. Her home is cluttered with small pathways for her to maneuver her walker through. She has many throw rugs placed throughout her home. A Cornell Scale for Depression in Dementia is designed for assessing depression in older people (Ori, 2012). Rhonda demonstrates multiple clinical signs of depression since her fall. She reports feeling frustration, despair and hopeless since falling and breaking her hip. She has slowly become socially isolated due to the inability to ambulate without assistance and she can no longer drive. A Mini-Mental State Exam (MMSE) has been performed by the Master Social Worker (MSW) due to changing mental status since the fall she experienced. There are 30 possible correct answers. These are divided into five general areas of memory and cognition. 1. Orientation: Does the person being tested have an awareness of time and place? This is where the tester asks the questions about the date, the season or time of year, and the location. 2. Registration: Can the subject find the words to name or identify objects, and can the subject memorize a list of three things? 3. Attention: Is the subject able to count backwards by 7s, or can the subject spell a word backwards (the preferred word to spell backwards is world)? 4. Recall: Can the subject remember and repeat the three items that were memorized earlier? 5. Language: Can the subject write a sentence, follow a simple written command, and copy a specific design? The MMSE score is adjusted to accommodate for any disabilities or inabilities that might affect the results ("The elder care," 2012). Rhonda scored 24 out of 30 evaluating her mild to moderate dementia.

5 GERIATRIC ANALYSIS PAPER Diagnoses Rhonda is experiencing multiple nursing diagnoses. Her number one diagnosis is Chronic pain related to physical disability and injury (Taylor & Ralph, 2008). Chronic pain is described as an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; pain may be of sudden or slow onset, vary in intensity from mild to severe, and be constant or recurring; pain lasts more than 6 months; and period of pain doesnt have an anticipated or predictable end (Taylor & Ralph, 2008). Rhonda is experiencing a great deal of pain related to the left hip replacement. Rhonda required a hip replacement after she experienced a serious fall and fractured her left hip. She also experiences defining characteristics such as; fear of re-injury, depression and weight loss. Rhondas second diagnosis is Risk for Injury related to motor deficits (Taylor & Ralph, 2008). At risk for injury is defined as At risk for injury as a result of environmental conditions interacting with the individuals adaptive and defensive resources (Taylor & Ralph, 2008). Rhonda experiences limited mobility, unsteady on feet and abnormal gait. Rhonda has a history of falls and is a fall risk according to the Fall Prevention Home Assessment ("Common screening and," 2012) that was performed. Rhondas third diagnosis is Impaired skin integrity related to physical immobilization (Taylor & Ralph, 2008). Impaired skin integrity is defined as Altered epidermis and/or dermis (Taylor & Ralph, 2008). Rhonda has developed pressure ulcerations on coccyx and heels bilaterally.

6 GERIATRIC ANALYSIS PAPER Planning As a home care nurse my job is to develop a plan of care to assist my patient towards improving the quality of their life. By doing so, the nurse must develop interventions that will assist in helping my patient to reach the goals that have been developed for them. The nurse will assess Rhondas physical symptoms, physical complaints and daily activities (Taylor & Ralph, 2008). The nurse will set up the patients pain medications in a medication box with the correct medication dosage and medication to be administered at the correct times. The patient will be closely monitored for the effectiveness of the medication when it is administered correctly. The patient will be monitored for the effectiveness of the medication while patient performs her activities of daily living. The nurse will correlate visits in order to observe Rhondas pain behavior during different times of the day. If the patient is pain free or has tolerable level of pain, continue plan (MidMichgan Health, 2011). The nurse will observe for factors that may cause or contribute to injury to increase awareness of the patient (Taylor & Ralph, 2008). The nurse will make recommendations to Rhonda that will improve her environmental safety and decrease the risk of falling and injury. The patient will be taught the correct use of adaptive devices to decrease the potential for injury (Taylor & Ralph, 2008). The nurse will educate the patient on household safety such as the importance of removing all throw rugs in the home and widening pathways to allow for safe ambulation. Keep the room clutter free and keep a night light on at night (MidMichigan Health, 2011). The nurse will assess Rhondas skin, wounds, and decubitus ulcerations at every visit made. The nurse will perform prescribed treatment regimen for the wound and skin

7 GERIATRIC ANALYSIS PAPER involved. The nurse will describe and document the patients skin and wound condition. Any changes will be reported to the physician to provide evidence of the effectiveness of the wound and skin care as ordered by the physician. The nurse will maintain infection control standards to reduce the risk of infection. Patient will be taught measures to reduce pressure on bony prominences, promote circulation, and minimize further skin breakdown. The importance of proper skin care requires keeping skin clean and dry. The nurse will discuss the importance of managing a balance diet and adequate fluid intake (Mid Michigan Health, 2011). Implementation To allow goals and outcomes to be evaluated, the nurse must first implement the plan that has been setup for the patient. One program run by Michigan Medicaid, is the MI Choice Waiver Program ("Department of community," 2012). A referral to the MI Waiver Program will be made for Rhonda. The waiver program can assist her in many ways. The program will provide Rhonda with an electronic medication dispenser allowing her to take the correct dosage and her medication at the correct time. In doing so will allow for better effectiveness of the pain medication. The waiver program will also provide homemaker services, chore services, personal emergency response systems, personnel care supervision, environmental modifications, and medical supplies and equipment not covered under the Medicaid State Plan ("Department of community," 2012). All of these services will assist Rhonda in many ways. The personal emergency response system will assist Rhonda to call for help if she experiences a fall. Since her fall in June, Rhonda has not been able to clean her home. The Waiver Program will assist her with homemaker services. She will be able to keep her home clean and uncluttered, allowing

8 GERIATRIC ANALYSIS PAPER her to ambulate in a safe environment. Rhonda will also be provided with chore services. This will allow for someone to wash her clothes and shop for her. Rhondas helpers will cook nutritional meals for her, as well as provide personal care. Rhonda will receive assistance with bathing. Doing so will allow the staff to monitor her skin for additional break down. Environmental modifications can be made to her home by widening doorways into the bathroom and bedroom. This allows Rhonda to enter the bathroom and bedroom with her walker. This will provide a safe environment for her, allowing her to stay in her home. Rhonda requires wearing pull up briefs due to her current incontinence issues. A referral to the Michigan Diaper and Incontinence Supplies Program will be made. Rhondas doctor will provide her a prescription for any of the following products she needs, which includes: All incontinence catheters and accessories Irrigation syringes Skin barriers Under pads Incontinence pants Incontinence liners Pull on Disposable diapers ("Michigan diaper and," 2012).

9 GERIATRIC ANALYSIS PAPER The program will provide pull up briefs for Rhonda. Rhonda will be more apt to change the incontinence briefs more frequently when they are provided for her. By doing so, her skin will stay dry and she will be less likely to develop further skin break down. The Commission on Aging (COA) is a leading multi-service agency that provides a community focal point for the needs of our adult population ("Welcome to the," 2012). Programs focus on assisting individuals who are sixty (60) years of age or older and live within our geographical service area ("Welcome to the," 2012). A referral to Commission on Aging will be made for Rhonda to receive services. Rhonda can no longer drive since her fall and she has multiple doctors appointments to attend. COA will provide transportation to and from appointments. They will also provide transportation to the Senior Center which will help alleviate some of the social isolation Rhonda is experiencing. Transportation services will allow Rhonda to re-gain some of her pre-fall independence and help reduce her depression. COA will also provide meals-on-wheels on days that her homemaker is not scheduled to help her. Evaluation After the patients plan of care is implemented, an evaluation of the plan of care is required in order for the healthcare team to see its effectiveness. The nurse observes Rhonda using the electronic medication dispenser correctly. She is taking the correct dosage at the correct time. Patient will be free if feasible or patients pain will be managed to a level tolerable that patient considers tolerable (MidMichigan Health, 2011). Using the Wong-Baker FACES Pain Rating Scale she rates the severity of her pain 4 Hurts Little More (Partners Against Pain, 2012). Patient demonstrates socialization behavior and activities (Taylor & Ralph, 2008).

10 GERIATRIC ANALYSIS PAPER After the implementation of the nurses recommendations the patient will be free of injury (MidMichigan Health, 2012). The patient applies safety measures (Taylor & Ralph, 2008). The patient demonstrates preventive measures to minimize potential injury (Taylor & Ralph, 2008). Rhonda demonstrates the ability to use adaptive equipment correctly. She ambulates with her walker as prescribed. After all of the recommendations are implemented, patients skin remains intact (Taylor & Ralph, 2008). Patients pressure ulcer heals as evidenced by presence of granulation tissue and decreased size and depth of ulcer (Taylor & Ralph, 2008). Rhonda verbalizes understanding the necessity of avoiding prolonged pressure, obtaining adequate nutrition, and keeping skin dry. Policy Problem Rhonda has many wrap around service needs, many of which are outside of the nurses scope of duties. Purpose Many referrals for services can be provided by other professional team members in order to allow the RN case manager to concentrate on the medical aspects of patient care. Although the agency has policies and procedures to facilitate the use of a Masters Level Social Worker for evaluation purposes, there is no policy or procedure for the utilization and referral process for a Licensed Bachelors Social Worker (LBSW) who can provide wrap around services to allow Rhonda to remain in her home setting. This policy will allow the nurse case manger more time to concentrate on their patients medical needs, thus allowing the nurse to provide quality care for each patient.

11 GERIATRIC ANALYSIS PAPER Procedure The agency has determined that any professional team member can make a referral to the agency scheduler who will obtain orders for the Medical Social Worker (LBSW) to complete an evaluation and obtain the necessary wrap around services to help the patient stay in their own setting or as a last resort to help facilitate placement in an appropriate alternative setting. Applicability The applicability of this policy is to all home care patients who present needs that fall within the purview of the medical social workers areas of expertise, and outside of the normal areas covered by the other team members disciplines. Conclusion In conclusion, elderly patients have a different set of needs. Many of these needs require immediate attention. Healthcare providers need to be aware the healthcare needs of the elderly in order to provide quality of care. With increasing life expectancy and number of older people, the positive outcomes of health promotion and disease prevention interventions for this age group are receiving significant attention (Toughy & Jett, 2012).

12 GERIATRIC ANALYSIS PAPER References

Common screening and assessment tools. (2012). Retrieved from http://www.fallpreventiontaskforce.org/tools.htm Department of community health-choices for older or disabled persons who may need help caring for themselves. (2012). Retrieved from http://www.michigan.gov The elder care team. (2012). Retrieved from http://www.eldercareteam.com/public/559.cfm Michigan diaper and incontinence and supplies program. (2012, 03). Retrieved from http://www.michigan.gov MidMichigan Health. (2011). Nursing care plans: fall risk-bed entrapment. Retrieved from http://www.intranet.gratiot/nursing-care-plans MidMichigan Health. (2011). Nursing care plans: urinary elimination, alteration-incontinence. Retrieved from http://www.intranet.gratiot/nursing-care-plans Ori, J. (2012). Depression assessment instruments. Retrieved from http://www.ehow.com/list_6909338_depression-assessment-instrum.. PartnersAgainstPain.org. (2012). Pain in the elderly: When someone you love is in pain. Retrieved from http://www.partnersagainstpain.com/pain-caregiver/elderly.aspx

Prevention Plus. (2010). History of the Braden scale. Retrieved from


http://www.bradenscale.com/index.htm Taylor, C. M., & Ralph, S. S. (2008). Nursing diagnosis reference manual. (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Touhy, T., & Jett, K. (2012). Ebersole, and Hess' toward healthy aging: Human needs and nursing response. (8 ed.). St. Louis: Elsevier Mosby.
Welcome to the commission on aging of isabella county . (2012). Retrieved from http://www.isabellacounty.org/dpt/coa/ MidMichigan Health. (2011). Nursing care plans: pain-alteration in comfort. Retrieved from http://www.intranet.gratiot/nursing-care-plans

13 GERIATRIC ANALYSIS PAPER Appendix A Braden Skin Assessment Tool


SENSORY PERCEPTION ability to respond meaningfully to pressurerelated discomfort 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of Consciousness or sedation. OR limited ability to feel pain over most of body 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over 2 of body 3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. 3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. 4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

MOISTURE degree to which skin is exposed to moisture

1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned

2. Very Moist Skin is often, but not always moist. Linen must be changed at least once a shift.

4. Rarely Moist Skin is usually dry, linen only requires changing at routine intervals 4. Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours 4. No Limitation Makes major and frequent changes in position without assistance 4. Excellent Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require

ACTIVITY degree of physical activity

1. Bedfast Confined to bed.

2. Chairfast Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair

3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair

MOBILITY ability to change and control body position

1. Completely Immobile Does not make even slight changes in body or extremity position without assistance

2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently

3. Slightly Limited Makes frequent though slight changes in body or extremity position independently.

NUTRITION usual food intake pattern

1. Very Poor Never eats a complete meal. Rarely eats more than a of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO and/or maintained on clear liquids or IV=s for more than 5 days

2. Probably Inadequate Rarely eats a complete meal and generally eats only about 2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding

3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN

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regimen which probably meets most of nutritional needs FRICTION & SHEAR 1. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction 2. Potential Problem Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down 3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. supplementati on.

Total

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15 GERIATRIC ANALYSIS PAPER Appendix B

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