Well-Executed Nursing Practice to Hospitalized Elderly Individuals - Essay Example

Critical Analysis of Literature Review - Nursing Introduction: Hospitalized elderly individuals with acute illness frequently have functional decline and loss of self-care skills. This prolongs hospital stay starting the vicious cycle of dependency and illness. Acute illness in elderly population is considered to serve both as a cause and effect of medical morbidity. Well-executed nursing practice can play a pivotal role in the care of these individuals in the hospital as well as in institutions like nursing homes. To execute preventive measures in a more effective way, clear analysis, description, and understanding of the patient's degree of functional incapacity on both medical and psychosocial angles are essential. Aging organ systems and senile changes in the brain may lead to cognitive dysfunction, and prolonged immobilization in bed due to the acute and critical illness may lead to irreversible physiologic changes, poor outcome at discharge, and for many, placement in a nursing home. To prevent this, ability to perform basic activities of daily life (ADLs), which are needed for personal self-care and IADLs or instrumental activities of daily living, which are needed for independent living need to be assessed. Whatever may the functional status of the patient be, it is necessary to determine the cause and treatment of any impairment. Socioeconomic and social support systems need to be assessed. It has exquisite importance in the nursing care of the elderly since diseases present atypically in the elderly, and acute functional decline may represent the first sign of a serious acute illness. In this work, functional status and its decline will be defined, and the contributing factors in hospitalized elderly patients will be examined. The tools to assess functional status will be explored, and an attempt at formulations of interventions to prevent the catastrophe of functional decline in the hospitalized elderly on the face of an acute illness will be made by means of extensive relevant literature review to enhance the fitness to practice. Definition of Functional Status: The interest in the functional status and functional assessment is growing. It is perceived by different authors from different angles. The American Thoracic Society Quality of Life Resource defines it to be an individual's ability to perform normal daily activities to meet basic needs to fulfill usual domestic and social roles (Leidy, N.K., 1994) and maintain health and well-being appropriate for age that subsumes into functional capacity and functional performance (Wilson, I.B., Cleary, P.D., 1995). Functional Performance: Functional performance, hence, is related to physical activities of daily living, simply assessed by self-report. Functional status can be influenced by biological and physiological impairment, symptoms, mood, and other factors like socioeconomic parameters. It is likely to be modified by the patient's health perceptions, for example, a person who thinks himself ill will have a poor functional status as measured by performance. Functional status is an aspect of health, and it is, in turn an aspect of useful, active life, and that becomes a problematic area in the elderly or geriatric age group. WONCA: In the perception of the World Organization of General Practice and Family Physicians (WONCA), it represents actual performance level or capacity to perform both in the sense of self-care or being able to fulfill a task or role at a given moment during a given period. The WONCA classification committee defines function as the ability of an individual to cope with and adapt to the changing elements in his or her individual environment and to perform certain tasks, like grooming, transferring, ambulating, bathing, and dressing to a measurable degree (WONCA Classification Committee, 1990). CICD: The Center to Improve Care of the Dying simply expresses this concept to be the ability to perform self-care, self-maintenance, and physical activities. This attempts to question the extent of individual ability to function normally and to carry out his/her physical activities. Alterations in function or functional decline in the elderly, especially in an acute care setting are commonly assessed at three sequential stages, impairment, disability, and handicap (Asberg, K.H., 1987). Differing Definitions: Such varying differences on a working definition calls for methods or instruments to both qualitatively and quantitatively measure functional or performance decline in the elderly individuals in the acute care clinical setting, so that may help formulate a preventative care plan to reduce incidence of dependency of these individuals. Contributing Factors: To understand these tools, it is important that the contributing factors causing functional decline in hospitalized elderly individuals are studied in a greater detail. The health status of the elderly individuals is often influenced by other frequently ignored factors like income level, living arrangements, and need for physical or psycho/social supports (Abraham, I. et al, 1999). Baseline Illness: The major focus of health promotion and improvement in the functional status is to minimize the loss of dependence associated with functional decline and acute illness superimposed on the baseline predominant chronic illnesses in this group of people (Rowe & Kahn, 1999). The picture appears more serious due to normal diminutive physiological changes of aging and increased risk of illnesses in the elderly. Problem Burden: In any country, of the people who are sick that seek medical care in the hospitals, the overwhelming majority is the elderly, and 48% of patients in the acute care setting are elderly (Mezey, M.D. et al, 1999). In diabetic elderly, visual impairment; in nondiabetics, muscle weakness of the extremities from osteoarticular impairment serves as the major contributing factor (Okada, T. and Nakao, T, 1998). Functional independence in the elderly population is directly related to muscle power than muscle strength related to leg power in the sedentary elderly population assessed by self-reported functional status, and functional status at baseline was discovered to be related to physiologic capacity, habitual physical activity level, neuropsychological status, and to the medical diagnosis with which the patient had been admitted (Foldvari, M. et al, 2000). Mechanism: A number of studies have assessed the extent to which loss of function across activities of daily living progresses hierarchically (Dunlop, D., 1997). There is a hierarchy involving the functions of daily living like bathing, dressing, toileting, transferring, feeding, and continence (Katz et al, 1983). The theory states, people lose abilities and become disabled opposite the order in which primary biological and psychosocial functions are acquired (Branch, L.G. et al, 1984). Predictability: This inculcates into determination and prediction of incident disability pattern as the hierarchy of dependency onset is assessed. With an appropriate instrument to measure, this can deliver quantitative data involving impairment of activities of daily living as people age to predict future disabilities in the remaining activities. Applied in the hospital setting where the elderly is cared for, this data on self- reported questionnaire could be applied to observed findings, and this may serve as a tool in the care plan. This may also help identifying the older people at risk of developing functional decline as a result of acute illness (Lazaridis, E.N. et al, 1994). Analysis: The most important denominator of functional decline is loss of independence in activities of daily living or instrumental acts of daily living. This, in turn, is a marker of decline and frailty in elderly adults and is, indeed, an indicator of healthcare use. Loss of activities of daily living refers to inability to perform a function within a range that is considered to be normal for independent living (Boult, C. et al, 1994). In the elderly individuals, decreased cognitive function is long known and shown to be related to loss of functional performance and related loss of independence. Along with that, advanced age in itself is a predictor of disability perhaps due to geriatric physiologic changes (Mor V et al, 1989). Although age and education are related to the cognitive functions, disability is directly correlated to hypermaturity of the organ systems and as a result can be an independent variable in genesis of functional decline with cognitive dysfunction with or without dementia (Institute of Medicine, 1991). Comment: This fails to correlate the patterns of development of functional decline and specific acute disease states for which the elderly seek care in the hospital setting. The relationship of functional decline and diminished performance as denominators of cognitive decline may well be related to environmental and socioeconomic factors like finances, family and social support systems, and baseline healthy life-style process. Synthesis: All compounded, activities of daily living consists of 18 functions that can be assessed easily with self-rated health questionnaire. These include personal hygiene, bathing and feeding self, toileting, use of stairs, dressing, bowel and bladder control, ambulation or wheel chair operation, chair to bed transfers and vice versa, use of telephone, shopping, food preparation, housekeeping, laundry, transport, responsibility for own medication, and ability to handle finances (Valderrama, E.et al, 2000). The most interesting common parameter for all of these functions is mobility, but it is evident that functional status as an indicator of health status cannot be assessed on the basis of diagnoses alone, one also needs a reliable method of assessing functional capacity. Measuring functional capacity is no substitute for a clinical examination. The basic idea of crude classification of individuals into those who need and who does not need assistance in case of functional decline obscures much limited functional capacity and reduced quality of life of individuals (Laukkanen, P., 2001). Tools: Not all activities are equally important or equally valuable, and there had been attempts to develop weighted scales to measure functional dexterity. These instruments all have inherent defects in design and validity for individuals vary in their assessments of the most important function of ADL. In the next section, a brief overview of different main tools to assess functional status will be discussed. The Northwestern Geriatric Functional Status Instrument: This is a four-domain screening tool to identify areas needing more in-depth assessment and/or intervention. The scoring system is dependant on physical status, cognitive status, ADLs and IADLs, and environmental and social factors assessments. The physical status assessment includes a complete physical examination and a formal motor and mobility evaluation. Each task is scored 0 or 1 except vision and hearing. For vision, a 20/20 vision is 2, 20/60 is 1, and errors allowed are 2 to 1. For hearing, each ear is assigned a score of 1, if the person can hear. Cognitive status is assessed by attention, memory, visual-spatial, and depression ratings. This can also be substituted by formal neurological examination, Folstein testing, or geriatric depression scale. ADL or IADL assessment questionnaire is designed in a fashion that better scores are indicated by a NO answer, but it is better to have a parallel family interview, patient observation in the hospital, Social Work verifications, and Case Management. If the subtotal score is low, it indicates the need for extensive post-hospital care services, and discharge planning should be made accordingly. Environmental and social risk factors that are crucial in patient care must be assessed (Saltzman, S., 1999). The Stanford Health Assessment Questionnaire (Fries, J.F., 1982): The HAQ measures difficulty in performing daily activities. The questionnaire is based on a hierarchical model that considers the effect of disease in terms of death, disability, and discomfort, the side effects of treatment, and medical costs. Apart from death, all other dimensions are divided into two subdimensions, upper and lower limb problems in disability dimension and physical and psychological problems for the discomfort dimensions. The scale measures 20 items on daily functioning during the past week, dressing and grooming, rising, eating, walking, hygiene, reach, grip, and outdoor activities. Each response is scored on a four-point scale of ability patterned from "without any difficulty" to "unable to do", and check list records aids used or assistance required. A total score of 0 to 24 provides a 0-3 continuous score to provide disability index. The Value of Current Interventions: The current literature can be synthesized to plan strategies that prevent and minimize the risk of functional decline (Inouye, S.K.et al, 2000). Risk assessment and risk management, identification of individuals at risk, and recognizing the risk factors for a functional decline, and the strategies implemented aims at reducing or eliminating risk factors and protecting the individual from further risks. Continuous evaluation of the quality and effectiveness of the care delivered (Vorhies, D., 1993), initial assessment using any tools is to be performed to assess the risk in a particular individual. If the risk is high, a daily care is implemented according to the standard guideline recommendations. With this, the care plan should be reviewed routinely as indicated by acute change or deterioration, a change in the patient's environment, or the patient's cultural beliefs, and the patient should be monitored more frequently (Gillepsie, L., 2004). The management is directed toward all the determinants; the intervention strategy will focus toward cognition and emotional health, mobility, vigour, self-care, and continence. The goals of management will be directed to maintenance of optimal cognitive functions, moral, and emotional health (Baldwin R, et al., 2003). For mobility, the strategy is to maintain muscle strength, endurance, and balance. Exercises and gait training play important roles, and falls-specific interventions are implemented (Latham, N., 2004). The interventions toward maintenance of fecal and urinary incontinence and appropriate catheter care and attention to nutrition and maintenance of skin integrity also constitute important strategies. Conclusion: The way forward is that of an integrated systemic approach with informed empathy for individuals for whom home is too far way. For older adults, effects of acute illness and hospitalization are superimposed on chronic risk factors for functional decline. Well integrated and planned interventions, which involves thorough and analytic assessment of these patients may help to plan a strategy to reduce dependency and enhance quality of life in these patients, and the greatest tool for accomplishing this is knowledge to augment quality of care. Reference List Abraham, I., Bottrell, M., Fulmer, T., & Mezey, M. (1999). Geriatric Nursing Protocols For Best Practice. New York: Springer Publishing Co. Asberg KH. Disability As A Predictor Of Outcome For The Elderly In A Department Of Internal Medicine. Scand J Soc Med 1987;15:261-265. Baldwin R, et al. Guideline for the Management of Late-Life Depression in Primary Care. International Journal of Geriatric Psychiatry 2003;18:829-38. Boult C, Kane RL, Louis TA, et al.Chronic Conditions That Lead To Functional Limitation In The Elderly. Journal of Gerontology, 1994;49:M28-M36 Branch LG, Katz S, Kniepmann K, Papsidero JA. A Prospective Study Of Functional Status Among Community Elders. American Journal of Public Health. 1984;74:266-268. Dorothy D. Dunlop, PhD, Susan L. Hughes, DSW, and Larry M. Manheim, PhD, Disabilities in Activities of Daily -Living: Patterns of Change and a Hierarchy of Disability, March 1997, Vol. 87, No. 3 American Journal of Public Health 378-379. Fries JF, Spitz PW, Young DY. The Dimensions Of Health Outcomes: The Health Assessment Questionnaire, Disability And Pain Scales. Journal of Rheumatology, 1982; 9:789-793. Gillepsie L, Gillepsie, WJ., Robertson, MC., Lamb, SE., Cumming, RG., & Rowe, BH. Interventions For Preventing Falls In Elderly People. The Cochrane Library 2004(2). Inouye SK et al., Predicting Functional Decline In The Hospitalized Elderly, J Gen Intern Med 1993 Dec; 8:645-652. Inouye SK, Bogardus ST, Jr., Baker DI, Leo-Summers L, Cooney LM, Jr. The Hospital Elder Life Program: A Model Of Care To Prevent Cognitive And Functional Decline In Older Hospitalized Patients. Hospital Elder Life Program. Journal of the American Geriatrics Society 2000;48(12):1697-706. Institute of Medicine. Disability in America: Toward a National Agenda for Prevention. Washington DC: National Academy Press;1991. Katz S, Branch LG, Branson MH, Papsidero JA, Beck JC, Greer DS. Active Life Expectancy. New England Journal of Medicine. 1983;309:1218-1224. Latham N, Anderson, C., Bennett, D. & Stretton, C. Progressive Resistance Strength Training For Physical Disability In Older People. In: The Cochrane Library 2004(2). Reference List Laukkanen, P., Pertti Karppi, Eino Heikkinen, and Markku Kauppinen, Coping With Activities Of Daily Living In Different Care Settings, Age Ageing, Nov 2001; 30: 489 - 494. Lazaridis EN, Rudgerg MA, Furner SE,Cassel CK. Do Activities Of Daily Living Have A Hierarchical Structure An Analysis Using The Longitudinal Study On Aging. Journal of Gerontology. 1994;49:M47-M51. Leidy NK. Functional Status And The Forward Progress Of Merry-Go-Rounds: Toward A Coherent Analytical Framework. Nursing Resident, 1994;43:196-202. Mezey, M.D., Stokes, S.A., & Rauckhorst, L.H. (1993). Health assessment of the older individual (2nd ed.). New York: Springer Publishing Company. Mona Foldvari, Maureen Clark, Lori C. Laviolette, Melissa A. Bernstein, David Kaliton, Carmen Castaneda, Charles T. Pu, Jeffrey M. Hausdorff, Roger A. Fielding and Maria A. Fiatarone Singh,, Association of Muscle Power With Functional Status in Community-Dwelling Elderly Women, The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 55:M192-M199 (2000). Mor V, Murphy J, Masterson-Allen S et al. Risk Of Functional Decline Among Well Elders. Journal of Clinical Epidemiology, 1989;42:895-904. Rowe, J.W. & Kahn, R.L. (1998). Successful aging. New York: Pantheon Books. Susan Saltzman, N.D., R.N., F.N.P., Functional Status Assessment, Northwestern University, Buehler Center on Aging, McGaw Medical Center, 1999. Tomonari OKADA, Toshiyuki NAKAO (1998), Physical Functional Status And Factors Contributing To Disability In Japanese Chronic Dialysis Patients, Nephrology 4 (3), 195-203, doi:10.1046/j.1440-1797.1998.d01-27.x Valderrama, E., Gama, J Damian, J Perez del Molino, M Lopez, M Perez, and F Iglesias, Short Report. Association Of Individual Activities Of Daily Living With Self-Rated Health In Older People, Age Ageing, May 2000; 29: 267 - 270. Vorhies D, Riley B. Deconditioning. Clinics in Geriatric Medicine 1993;9(4):745. Wilson IB, Cleary PD. Linking Clinical Variables With Health-Related Quality Of Life. JAMA 1995;1995:59-65. Read More