Geriatric Category Patients and Their Treatment - Essay Example

?Assessment: Case Study Client Assessment Taking care of a geriatric patient is a time consuming, continuous nursing activity; as such patients are subject to rapid deterioration, due to one reason or the other, as they are usually afflicted with multiple conditions requiring continuous medication and constant monitoring. Some of the pharmacological and non-pharmacological interventions, such patients’ are subjected to, may be contradictory in nature and may require emergency treatment. Evidence based, judicious decisions therefore need to be taken at each instance, making the task onerous as well as difficult for the nursing practitioner. Healing, especially, has been identified as an issue in the elderly’ due to characteristic age related changes in skin texture, reduced processes of wound healing which are clearly distinct from the rapid healing in young patients (Gosain & Dipietro, 2004: 321). The particular patient shortlisted for this assessment belongs to the geriatric category as he is an 80 years old man, with an established diagnosis of Chronic Obstructive Pulmonary Disease (COPD), probably precipitated due to a history of excessive smoking. The man has also suffered an episode of shingles, as revealed from his medical history sheet. Due to the multiple comorbidities he is suffering from, he is currently being administered a combination of medications, which complicate his care further due to the multifarious side-effects associated with them. Taking history of a patient is an art which needs to be mastered by each nursing professional. It needs preparation of a proper environment, good communication skills of the nursing practitioner, and is a thoroughly systematic, sensitive and professional activity (Lloyd & Craig, 2007: 42). The Calgary Cambridge Framework, a widely accepted standard for collecting the anamneses of a patient is generally recommended and includes five stages which summarize the history taking process (Lloyd & Craig, 2007: 44). The first of the five stages’ includes proper establishment of consensus between the patient and the nursing practitioner that the history has been taken appropriately, aiding the patient to accurately recall and comprehend the posed queries, achievement of a shared understanding between the patient and the nurse for establishment of a true interaction, proper planning for shared decision making with the patient’s compliance, and closing the consultation amiably in accordance with the patient’s expectations (Lloyd & Craig, 2007: 44). Unhelpful interview techniques involving questions which are too probing, offensive, misleading or inappropriate are expressly prohibited in the Calgary Cambridge Framework. The framework advises against the use of defensive responses and tendency to jump to conclusions. A properly structured sequence of questioning aimed at obtaining comprehensive information about the patient's condition yielding pertinent data should be strictly followed. Discretion should be employed while obtaining answers to sensitive questions such as sexual and social history, and while gathering details about alcohol, tobacco or substance abuse (Lloyd & Craig, 2007: 47). The patient shortlisted for assessment is dependent on PEG tube for feeding but is fully capable of taking care of his toilet and bathing needs with some guidance. Currently he suffers from cellulitis, especially in the lower body and the resultant wounds in both legs are causing considerable pain. The severely affected left leg is kept raised to reduce his discomfort and the wound is dressed aseptically on a daily basis. On immediate observation, the patient is afebrile, has a blood pressure (BP) of 140/95, a respiration rate (RR) of 20-37, and a heart rate (HR) of 80 beats per minute. His health parameters have consistently remained at this level for the last few days with only slight variations. However, as the patient was a regular smoker with an established diagnosis of COPD, he is in need of special care and oxygen therapy due to his compromised respiratory system condition. History of an episode of a severe shingles attack reveals that immunity of the patient is compromised and he needs to be protected from all sources of new infection. The patient has already suffered an episode of infection with ‘Methicillin Resistant Staphylococcus aureus’ (MRSA), a serious life threatening malady which can be fatal if not treated with appropriate antibiotics. Assessment of a patient is the most crucial step which determines the future course of action by a nursing practitioner. Assessment has been defined as the process of collecting, validating and clustering patient data in order to arrive at a broader picture which defines the future course of action (Dillon, 2007: 4). It does not stop at the initial examination of the patient and perusal of history, but is a continuous process which takes into account the therapeutic modalities being applied, the responses obtained as a result, and the evaluation of effectiveness of the nursing plan being utilized to treat the patient (Dillon, 2007: 5). For this particular patient the general survey should include examination of the whole body at a glance. As the patient has been fitted with a PEG tube, it should be ensured that the tube is firmly in place and not causing any physical distress. The oral cavity should be examined for dryness or any signs of bad odor. Similarly the nasal cavities should be free from any kind of abnormal discharge and should be examined for signs of dryness which can be expected at this advanced age. Patients fitted with PEG tubes require special attention as some of the oral medications may need to be administered through the tube on several occasions during a 24 period. Appropriate dosage form of the drug, preferably in liquid form needs to be used in such patients. In cases, where the liquid dosage form is not available, a tablet may need to be crushed, dissolved in sterile water and administered through the PEG tube by flushing with adequate amounts of water, before as well as after the actual medication has been delivered. The nursing practitioner must take care that no drug contraindicated to be administered through PEG tube by crushing is administered inadvertently. Such oral medications include the ones which are intended for sub-lingual route, are enteric coated, or contain excipients which might turn harmful when the tablet is crushed. In case of doubt, expert opinion from seniors and the prescribing physician should be sought while administering oral medications through the PEG tube. For this particular patient, the prescribed medications, their dosage, the intended therapeutic action, and the possible side effects are described in Table I: Table I: Current Medications being administered to the Patient S. No. Medication Route Therapeutic Goal Possible Side Effects 1 Norspan 10 µg/hour (Buprenorphine) Trans-Dermal Analgesia. Pain relief from cellulties & resultant wounds Respiratory depression, drowsiness 2 Asmol uni-dose 2.5 mg every 2 hours (Salbutamol) Inhalation via nebulizer Respiratory assistance. Relaxes broncho pulmonary smooth muscles Anaphylaxis, Reduced BP 3 Atrovent 500 µg every 4 hours (Ipratropium) Inhalation via nebulizer Prevention of bronchospasm Dryness of mouth, throat irritation, constipation, diarrhea, urinary retention 4 Gastro Stop 2 mg prn (Loperamide) Oral Anti diarrheal agent (Opioid) Anticholinergic effects like constipation, urinary retention, glaucoma, intestinal stasis 5 Panafcort 5 mg (Prednisone - synthetic corticosteroid) Oral Potent Anti inflammatory action to treat cellulitis Anaphylaxis, predisposition to infection 6 Frusemide 40 mg Diuretic Oral Enhancement of urination 7 Solprin 150 mg (half tablet) Oral Analgesic, blood thinner to control high BP Gastroesophageal reflux, tendency to bleed 8 Acimax 20 mg x 2 (twice daily) Omeprazole Oral Proton pump inhibitor to control acidity and gastroesophageal reflux Anaphylaxis, inflammation of soft tissues like lips, face and tongue While administering medications through a PEG tube, care should be taken that medications are given in strict compliance with the physician's order. The patient should be psychologically prepared and informed about the daily routine and specific timings for the medication administration, so that he is psychologically prepared for the same. The timing should be such that it does not interfere with the normal feeding of diet through the PEG tube. There should be a gap of 1-2 hours between oral medication and normal feeding. Preferably liquid dosage forms of the prescribed medication should be chosen for the patient. If this is not possible, the tablet should be crushed meticulously and mixed with an appropriate quantity of water in which it should be dissolved completely. Strict hygiene should be practiced. The vessels in which the dilution is done should be sterile and the person administering the drug should wear sterile gloves before indulging in the actual procedure. The placement of the PEG should be verified every time, whenever a fresh oral medication is about to be administered. This is accomplished by aspirating the gastric fluid each time and subjecting it to a litmus test to determine that the contents are acidic. This confirms that the other end of the PEG tube is correctly placed in the stomach. The PEG tube should be thoroughly flushed with approximately 60 ml or more of sterile water and the medication recently administered should be documented in the patient's record without fail. A general examination should also include examination of the skin, movement of the joints and signs of any abnormality should be brought to the notice of the attending physician immediately. Superficial examination of the whole body reveals that the patient is suffering from festering wounds on both legs in the area below the knee. The left leg has a large wound 7 cm below the knee and the right leg has multiple wounds in the same area. This observation reveals that the patient is prone to infection in distal areas of the body, probably due to low circulation and inability to maintain hygiene, specifically in the lower region of the body. Probably, as the patient is able to visit the toilet, he is not able to clean himself properly, and needs nursing assistance for the same. As the patient has an established diagnosis of COPD, the respiratory system needs careful examination. The respiration rate should be observed at the first instance. Respirations should be regular and unlabored. There should be no cough; breathing sound should be clear with absence of adventitious sounds (Dillon, 2007: 399). Occurrence of dyspnea, cough or chest pain should be immediately brought to the notice of the attending physician. Patients with COPD have an already compromised state of respiration and they should be evaluated according to their historical data for respiratory markers such as depth and strength of respiration and the respiration rate itself. Any respiratory medications if taken in the past may make the patient dependent on them and the past medication history for at least three months should be taken into account while evaluating the respiratory status of an aged patient. History of smoking, as in the current patient is an indicator of reduced efficacy of the lungs due to damage to the alveoli and emphysema. As this patient is 80 years old, the alveoli and the lung parenchyma are likely to be less elastic and sparse in tissue content respectively. The variation of the RR from 20 to37, as observed in this patient reveals reduced functioning of the lungs and the patient might need external support such as oxygen mask whenever an instance of acute respiratory distress is observed. Respiration rate should be evaluated before and after physical exertion. If there is exacerbation of respiratory distress upon physical exertion, it should be brought to the notice of the physician. As of now, the patient is on a continuous oxygen therapy via an oxygen concentrator to address the increased oxygen demand due to poor functioning of his lungs. Assessment of the abdominal region reveals nothing as no abnormal mass is palpable, and the sounds on auscultation reveal nothing. Malfunctioning in the cardiovascular system is manifested as chest pain, fatigue, and shortness of breath, general fatigue, back pain, anorexia and light-headedness (Dillon, 2007: 456). Measurable modalities leading to establishment or indication of any existing cardiovascular pathology include HR, BP (Blood Pressure), ECG (Electrocardiograph) and oximetry besides general auscultation which can reveal abnormal cardiac sounds or murmurs requiring further investigation. The BP 0f 140/95 and a HR of 80 beat per minute in this particular patient reveal that he is suffering from mild hypertension. The HR can be considered within normal limits as at such advanced age, the cardiovascular musculature is likely to undergo some degree of regressive changes, reducing their overall functionality. There is no neurological dysfunction as the patient is conscious and aware of his surroundings. He is capable of handling his toiletry needs with some assistance. Neurological dysfunction is revealed by disorientation and in-coordination of movements of any limb, or twitches, none of them being observable in this patient. Similarly musculoskeletal system is normal and just lacks the strength and mass which is expectable at this advanced age. Major Clinical Problem The major clinical problem identified in this client is cellulitis and the resultant festering wounds in the legs which need to be cured at the earliest. Pain management is also an issue in this patient. History of MRSA infection is a worrying area as the client might be re-infected if adequate precautions are not taken. Accompanying psychological distress is another issue as geriatric patients are extremely susceptible to depression. Poor functioning of the lungs is another area to be focused at, as spontaneous breathing without external support is the desired therapeutic goal. The client needs a proper assessment of the extent of wounds on his legs and the therapeutic modalities available for initiating a rapid healing process. Factors influencing healing of leg ulcers in the elderly include ulcer size, duration, age of the patient and mobility constraints in the affected limb joint as well as the patient (Edwards et al, 2005: 170). This has given rise to the emergence of specialized 'leg-ulcer clinics' worldwide which report a higher rate of recovery in such patients. Availability of trained nursing professionals' with specialization in wound healing skills, and the technique of multilayered compression bandaging materials have been suggested as the reasons for success of such clinics. Problems encountered during healing of chronic leg venous ulcers include factors such as patient non-compliance, altered psychological status, the mode and type of the treatment modality selected, and the complications secondary to coexisting morbidities (Edwards et al 2005: 175). Ulcer healing level needs to be evaluated by measuring the area of the wound by a technique known as the dot-point method, and the progress of healing is evaluated by a scale labeled as the ‘Pressure Ulcer Scale for healing’ (PUSH) scale (Stotts et al, 2001: M795). Both these values have are pertinent in the evaluation of healing of wounds in the elderly. Assessment of the degree of pain being experienced by the client is another vital area of nursing practice. Multifarious tools and scales are available for assessment of pain. This particular client is presently experiencing pain in the legs due to the multiple wounds in both legs for which he is on a continuous medication with paracetamol. Pain alleviation in the elderly however should be interplay of pharmacological as well as non-pharmacological approaches. Pain is a phenomenon which results due to complex interaction between the precipitating physical cause (open wounds in this case), and the patient’s psyche (Piotrowski et al, 2003: 1037). From a nursing perspective it is essential that the issue is addressed from a broader perspective, by making use of drugs as well as psychotherapy. This is true because the actual manifestation of physical pain is due to an interaction of both sensory and affective components (Piotrowski et al, 2003: 1037). The sensory component includes neuro-humoral mechanisms which convey the sensation from the locus of injury to nociceptive receptors within the brain and is expressed in relation to time, intensity, location, pressure and thermal gradients. The affective component of pain, on the other hand, involves an emotional component, through which the sufferer identifies pain as an unpleasant experience. Tension, fear and responses in the autonomic nervous system contribute to the experience of pain as an unpleasant experience, varying in degree and intensity in individual patients (Piotrowski et al, 2003: 1041). These factors need to be considered in the current client in order to address the primary issue of pain. Professional pain management by nursing professionals should involve a holistic approach (Winn & Dentino, 2004: 342). The holistic approach includes consideration of physical, emotional, social and spiritual aspects connected with the patient (Winn & Dentino, 2004: 342). Repeated evaluations of chronic pain and aggressive treatment have been recommended by the author as a routine measure. Peripheral arterial disease (PAD) is a condition encountered in majority of elderly patients in which there is reduced blood flow to the lower extremities (Federman et al, 2004: 26). PAD increases exponentially with age and in older patients like this client, the incidence is as high as 50% (Federman et al, 2004: 26). Proper treatment and nursing care of such elderly patients is a primary concern in the present healthcare setting, as the population of elderly patients’ increases day by day. Elderly patients have a tendency towards non compliance of the healthcare practitioner's directions and usually forget to take oral medications. They need to be constantly observed and reminded repeatedly to follow the recommended dosage schedules as well as make lifestyle changes suggested by the physician (Treichel, 2008: 25). Making lifestyle changes is the most difficult aspect for them to master as old habits die hard. Further complications arise due to the presence of myriad cognitive disorders and concurrent co-morbidities afflicting such patients. Reduced cardiac functioning, diabetes, obesity, neurological diseases such as Parkinsonism and dementia are some of the disorders afflicting the elderly patient population. Another complicating factor is the lack of sincere friends, loss of a life partner and family support which contribute to depressive states in such patients. Some of the elderly patients may have had eminent roles in their own professional capacities during youth which makes them too proud to seek assistance, although in dire need. Such elements of dignity and helplessness are juxtaposed in a manner that makes nursing care of such patients even more difficult. Elderly patients therefore need to be handled with professional firmness, as well as meticulous patience, which are difficult nursing arts to master (Lewis et al, 2007: 485). The best method of chronic pain alleviation is however definitely the pharmacologic approach and the choice of the pharmacological agent should be through proper evaluation of the nature of injury, the type of pain and the physical/psychological characteristics of the patient. Drug dosage needs to be closely monitored and modified according to individual requirements with constant monitoring and careful observation. A holistic approach includes usage of non-pharmacological modalities such as physiotherapy and behavioral therapies. Application of heat pads, cold compresses, massage, trans-cutaneous nerve stimulation, chiropractic/osteopathic manipulations, acupressure and magnetotherapy are the manifold physical approaches being employed nowadays (Winn & Dentino, 2004: 347). Other, non-physical components of pain alleviation include meditation, prayer, aromatherapy and music which divert the patient's attention and build tolerance from within (Winn & Dentino, 2004: 347). Another primary area of concern is this patient is assessing his need for pulmonary rehabilitation as he has a confirmed diagnosis of COPD requiring continuous oxygen support. A pulmonary rehabilitation program includes facilitation for attaining a post therapeutic normal pattern of life in which he is able to breathe spontaneously. This depends upon the disease stage, prognosis as well as psycho somatic condition of the patient. An effective pulmonary rehabilitation program increases exercise tolerance in patient, improves walking performance, raises the quality of life, reduces symptoms and brings the patient into a community of support and shared experience (Carr et al, 2007: 132). However pulmonary rehabilitation cannot be achieved in patients who lack motivation, do not adhere to recommended therapeutic protocols, posses inadequate financial resources, have severe cognitive dysfunction or psychiatric illness or unstable comorbidities like angina and congestive heart failure, are unable to exercise and indulge in cigarette smoking. In this particular patient, pulmonary rehabilitation will be a secondary therapeutic action once the problems associated with cellulitis and the resultant wounds are addressed. However, a constant assessment and monitoring of respiratory parameters such as tidal volume, blood gases, forced expiratory volume (FEV), respiration rate and vital capacity is essential. Another area of concern is the previous infection of the patient with MRSA (Methicillin resistant Staphylococcus aureus). Staphylococcus aureus is a bacterium present on the skin or inside the nose of an average healthy person and usually colonizes 25-30% of the human population, particularly the ones living in unhygienic conditions (Gordon & Lowy, 2008: S350). Any delay in the isolation of the organism and treatment can have fatal outcomes. The infection causes local inflammation and cellulitis with intense pain and discomfort without any febrile condition. Lack of treatment can lead to ingress of infection into internal organs especially in patients with compromised immune systems 5 major clones have been identified so far which can lead to serious infections in hospitalized patients (Gordon & Lowy, 2008: S353). These clones are resistant to a multitude of antibiotics, and treatable only with Vancomycin, a parenteral antibiotic drug. A proper assessment by bacteriological examination of exudates from the patient is therefore necessary to rule out re-infection with the organism. Recommendation The actual problems afflicting the client are cellulitis, inability to breathe spontaneously, inability to take food on his own, festering wounds beneath the knees on both legs and general debility associated with old age and the associated distress due to pain. The contributing factors include excessive smoking in the past that resulted in COPD, history of testing positive for MRSA infection and hypertension. The prognosis for the patient is grave, as the presented co morbidities are difficult to treat at such an advanced stage of his life. Healing processes are slowed down during old age and the lack of immunity makes such patients susceptible to fresh infections. The initial therapeutic endeavor should be aimed at healing the wounds after which pulmonary rehabilitation can be tried. If the patient is able to overcome these hurdles, the PEG tube can be removed after he gains and strength and acquires the capability to eat normally and carry out his daily activities independently. He needs constant nursing care and psychological support until the therapeutic goals are achieved. For the time being, the therapeutic aim is to adequately manage the pain being suffered by the patient, ensure that the wounds get healed in an adequate time frame and the patient is able to re establish himself independently as near to the normal status for a patient belonging to his age group. References Carr, S. J., Goldstein, R. S. and Brooks, D. 2007 Acute Exacerbations of COPD in subjects completing Pulmonary Rehabilitation. CHEST, 132, 1, 127-134. Dillon, P.M., 2007. Nursing Health Assessment. 2nd Ed., F.A. Davis, Philadelphia. Edwards, H., Courtney, M., Finlayson, K. et al. 2005 Improved healing rates for chronic venous leg ulcers: Pilot study results from a randomized controlled trial of a community nursing intervention, International Journal of Nursing Practice, 11, 4, 169-176. Federman, D. G., Bravata, D. M. and Kirsner, R. S. 2004 Peripheral arterial disease - A systemic disease extending beyond the affected extremity, Geriatrics, 59, 4, 26-36. Gordon, R.J. & Lowy, F.D. 2008 Pathogenesis of Methicillin-Resistant Staphylococcus aureus Infection, Clin. Infect. Dis., 46, 5, S350–S359. Gosain, A. & DiPietro, L.A. 2004 Aging and Wound Healing, World J. Surg., 28, 321-326. Lewis, M., Nevoa, I., Paniaguaab, A. et al. 2007 Uncomplicated general anesthesia in the elderly results in cognitive decline: Does cognitive decline predict morbidity and mortality?, Medical Hypothesis, 68, 3, 484-492. Lloyd, H. and Craig, S. 2007 A guide to taking a patient's history, Nursing Standard, 22, 13, 42-48. Piotrowski, M.M., Paterson, C., Mitchinson, A. et al. 2003 Massage as Adjuvant Therapy in the Management of Acute Postoperative Pain: A Preliminary Study in Men, J. Am. Coll. Surg., 197, 1037-1046. Stotts, N., Rodeheaver, G., Thomas, D. et al. 2001 An Instrument to Measure Healing in Pressure Ulcers: Development and Validation of the Pressure Ulcer Scale for Healing (PUSH)', Journals Of Gerontology Series A: Biological Sciences & Medical Sciences, 56A, 12, M795-M799 Treichel, J. A. 2008 Cognitive Impairment affects 1 in 5 Elderly Americans, Psychiatric News, 43, 8, 25. Winn, A.S. & Dentino, A.N. 2004 Effective Pain Management in the Long-Term Care Setting, J. Am. Med. Dir. Assoc., 5, 342–352. Read More