A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients; they have more admissions to the hospital from the emergency department and more and longer hospital stays, and they use more resources while in the hospital. Show
In 2015, almost 57,000 adults over age 65 visited the emergency department (ED), and 33.6% of those patients were admitted to the hospital, a 20% decrease from the 42% admitted in 2006 ( 1 Emergency department care reference A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients... read more ). Older patients tend to be sicker. Some hospitals now have special geriatric EDs staffed with geriatric-trained nurses and physicians, which may be contributing to the reduction in hospital admissions ( 2 Emergency department care reference A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients... read more ). More than 50% are prescribed new drugs. Older adults may use the ED as a substitute for primary care or may come because they are not receiving adequate attention from their primary care physician. ED visits are often caused by a breakdown in the social structure of a frail older patient—eg, absence or illness of their caregiver may result in people calling an ambulance rather than going to their physician's office. However, in many cases, the reasons for coming are true emergencies. A visit to an ED may create more stress for older adults because there are typically no special accommodations for them (eg, quiet rooms, lower beds, extra pillows, indirect lighting). However, some hospital systems are creating special geriatric EDs, which are spaces in the regular ED dedicated to the care of older adults. These geriatric EDs have geriatric-trained physician and nursing staff as well as specialized equipment, such as gurneys with pressure-reducing mattresses that reduce risk of pressure injuries and improved lighting and acoustics to promote vision and hearing. Evaluation of an older adult usually takes longer and requires more diagnostic tests because many older patients do not present with clear-cut or typical symptoms and signs of a disorder. For example, myocardial infarction manifests as chest pain in < 50% of patients > 80 years. Instead, older patients may complain of feeling generally weak or just not feeling themselves. Factors that are not apparent (eg, polypharmacy, adverse drug effects) may affect an older patient’s presentation. For example, a fall may result from abuse, an adverse drug effect (eg, oversedation), hazards in the home, physical problems (eg, poor vision), depression, or chronic alcoholism. Adverse drug effects account for at least 5% of hospital admissions for older adults. About 30 to 40% of older patients who come to the ED are cognitively impaired but do not have a diagnosis of dementia; in 10%, cognitive impairment consistent with delirium is unrecognized. When indicated (eg, if an older patient is having difficulty with orientation to person, place, or time), a standardized cognitive assessment How to Assess Mental Status The patient’s attention span is assessed first; an inattentive patient cannot cooperate fully and hinders testing. Any hint of cognitive decline requires examination of mental status ( see Examination... read more should be done in the ED. However, a standardized cognitive assessment is appropriate for any older patient coming to the ED. Cognitive impairment affects the reliability of the patient history as well as the diagnosis, increases the risk of delirium during a hospital stay, and must be considered when planning the patient’s disposition. Knowing whether onset of cognitive impairment is recent helps determine whether the impairment should be fully assessed in the ED. Cognitive impairment of recent onset may indicate sepsis, occult subdural hemorrhage, or an adverse drug effect. Suicide risk, fall risk, incontinence, and nutritional and immunization status should be assessed in the ED so that follow-up care can be arranged. Good communication among ED physicians and patients, caregivers, primary care physicians, and staff members of long-term care facilities greatly enhances the outcome of older patients with complicated problems. Advance directives should be promptly and clearly communicated to emergency medicine practitioners. Baseline information from the patient’s personal physician facilitates assessment and management planning in the ED. Reports to the patient’s primary care physician should describe even simple injuries (eg, ankle sprain, Colles wrist fracture) because such injuries can dramatically affect functional ability and independence. Discharge planning may be complex because acute illness or injury may impair functional ability more in older patients (eg, a simple ankle sprain may be incapacitating unless patients have good support at home). Discharge planning may be improved when nurses, social workers, and primary care physicians are involved. It should include the following:
Many older patients are hospitalized after they are evaluated in the ED. Occasionally, older patients are brought to the ED by a caregiver who refuses to take them home or who leaves, abandoning them in the hospital.
Hospitalization can magnify age-related physiologic changes and increase morbidity. Only seriously ill older patients who cannot be appropriately cared for elsewhere should be hospitalized. Hospitalization itself poses risks to older patients because it involves confinement, immobility, diagnostic testing, and treatments (particularly changes in drug regimens). When patients are transferred to or from a hospital, drugs are likely to be added or changed, leading to a higher risk of adverse effects Reasons for Drug-Related Problems Drug-related problems are common in older adults and include drug ineffectiveness, adverse drug effects, overdosage, underdosage, inappropriate treatment, inadequate monitoring, nonadherence... read more . Treatment in hospitals can be dehumanizing and impersonal. Acute hospital care should last only long enough to allow successful transition to home care, a skilled nursing facility, or an outpatient rehabilitation program. The outcome of hospitalization appears to be poorer with increasing age, although physiologic age is a more important predictor of outcome than is chronologic age. Outcome is better for patients hospitalized because of elective procedures (eg, joint replacement) than for those hospitalized because of serious disorders (eg, multisystem organ failure). About 75% of patients who are ≥ 75 and functionally independent at admission are not functionally independent when they are discharged; 15% of patients ≥ 75 are discharged to skilled nursing facilities. The trend toward abbreviated acute hospital stays followed by subacute care and rehabilitation in a skilled nursing facility may partially explain why these percentages are high. However, even when a disorder is treatable or appears uncomplicated, patients may not return to prehospital functional status. Studies have shown that patients who receive moderate intensity exercise while in the hospital, particularly exercises that focus on walking, resistance, and balance training, did not experience any functional decline during their hospitalization ( 2 Hospitalization references A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients... read more ). This highlights the importance of ensuring that older adults start physical therapy as soon as possible while in the hospital. The following strategies can help reduce functional decline and improve care of older patients:
Advance directives, if already prepared, should be brought to the hospital as soon as possible. Practitioners should reaffirm these choices during acute hospitalization. If directives were not documented, practitioners should make every effort to determine the patient’s wishes. 
Hospitalization rates due to adverse drug effects are 4 times higher for older patients (≈ 17%) than for younger patients (4%). Reasons for these effects include
Maintaining a daily list of drugs prescribed and received can help prevent adverse drug effects and drug interactions. Because drug distribution, metabolism, and elimination vary widely among older patients, the following should be done:
Prolonged bed rest, as can occur during hospitalization, causes deconditioning and is seldom warranted. The resulting inactivity has the following effects:
After even a few days of bed rest, older patients who have reduced physiologic reserves but can still function independently may lose that ability. Even if the loss is reversible, rehabilitation requires extensive, expensive, and relatively lengthy intervention. In older patients, bed rest can cause vertebral bone loss 50 times faster than in younger patients. The loss incurred from 10 days of bed rest takes 4 months to restore. Nurses should ensure that the hospital aligns care with the American Academy of Nursing recommendation that walking during the hospital stay is critical for maintaining functional ability in older adults. Unless prohibited for a specific reason, activity (particularly walking) should be encouraged. If assistance with walking is needed, therapists may provide it at scheduled times. However, physicians, nurses, and family members should also assist patients with walking throughout the day. Hospital orders should emphasize the need for and promote activity. If immobilization is necessary or results from prolonged illness, procedures to prevent deep venous thrombosis are recommended unless contraindicated. Rehabilitation is often needed. Realistic goals for rehabilitation at home can be based on the patient’s prehospitalization activity level and current needs; orders for home physical and/or occupational therapy should be considered. Age-related changes (eg, baroreceptor insensitivity, decreased body water and plasma volume) result in a tendency to develop orthostatic hypotension. These changes plus effects of bed rest and use of sedatives and certain antihypertensives increase risk of falls (and syncope). Among hospitalized older patients, > 60% of falls occur in the bathroom; often, patients hit hard objects. Some patients fall while getting out of chairs and hospital beds. Patients are in a strange bed and in a strange environment, and they may easily become confused. Although bed rails may help remind older patients to call for assistance before attempting to get up, bed rails may also tempt patients to climb over or around them and thus may contribute to patient falls. Bed rails are generally discouraged because of the increased fall risk. Usually, bed rails should be removed or kept down. The best alternatives to the use of physical or chemical restraints are to identify, carefully analyze, and modify or correct risk factors for falling (including agitation) and to closely observe patients at risk. Using low beds with padding on the floor next to the bed for patients with cognitive impairment, making sure any fluid spills are cleaned up promptly, and keeping pathways in rooms and hallways clear may also help reduce the risk of falls. Urinary or fecal incontinence develops in > 40% of hospitalized patients ≥ 65, often within a day of admission. Reasons include the following:
Bedpans may be uncomfortable, especially for postsurgical patients or patients with chronic arthritis. Patients with dementia or a neurologic disorder may be unable to use the call bell to request toileting assistance. Fecal impaction, gastrointestinal tract infection (eg, Clostridium difficile–induced colitis), adverse effects of drugs, and liquid nutritional supplements may cause uncontrollable diarrhea. With appropriate diagnosis and treatment, continence can be reestablished in many cases. Older patients may appear confused because they have dementia, delirium, depression, or a combination. However, health care practitioners must always remember that confusion may have other causes, and its presence requires thorough evaluation. Confusion may be due to a specific disorder ( see Table: Causes of
Delirium Causes of Delirium Family members can be asked to bring missing eyeglasses and hearing aids. Placing a wall clock, a calendar, and family photographs in the room can help keep patients oriented. The room should be lit well enough to enable patients to recognize what and who is in their room and where they are. When appropriate, staff and family members should periodically remind patients of the time and place. Procedures should be explained before and as they are done. Use of physical restraints is discouraged. For agitated patients, restraints invariably increase the level of agitation. Identifying and modifying risk factors for agitation and closely observing patients can help prevent or minimize it. Invasive and noninvasive devices attached to patients (eg, pulse oximeters, urinary catheters, IV lines) can also cause agitation; the risk:benefit ratio of these interventions should considered.
Pressure injuries Pressure
Injuries Pressure injuries are areas of necrosis and often ulceration (also called pressure ulcers) where soft tissues are compressed between bony prominences and external hard surfaces. They are caused... read more Hospitalization contributes to undernutrition in several ways:
Patients with preexisting nutritional abnormalities should be identified when admitted and be treated appropriately. Physicians and staff members should anticipate nutritional deficiencies in older patients. The following measures can help:
A care transition is whenever a patient moves from one setting of care to another. In the last decade, significant research has shown that patient care during transitions is fragmented, frequently rushed, and lacks communication between practitioners, all of which result in poor patient outcomes. Transitions of care are when the greatest numbers of errors occur, creating increased risk for morbidity and mortality, particularly to older adults who cannot always advocate for themselves. Practitioners who provide care to older adults must pay special attention to the many transition points that occur when an older adult comes into the health care system. Best practices include ensuring that
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
Early, effective discharge planning has many benefits:
As soon as a patient is admitted, all members of the interdisciplinary team begin discharge planning. A social worker or discharge planning coordinator evaluates the patient’s needs within 24 hours of admission. Nurses help physicians determine when discharge is safe and which setting is most appropriate. Patients being discharged to their home need detailed instructions about follow-up care, and family members or other caregivers may need training to provide care. If patients and family members are not taught how to give drugs, implement treatment, and monitor recovery, adverse outcomes and readmission are more likely. Writing down follow-up appointments and drug schedules may help patients and family members. At discharge, a copy of a brief discharge summary plan should be given to patients or family members in case they have questions about care before the primary care physician receives the official summary plan. When a patient is discharged to a nursing home or to another facility, a written summary should be sent with the patient, and a full copy should be sent electronically to the receiving institution, also, a phone call should be made to the receiving facility. Ideally, the discharging practitioner should call the physician, nurse practitioner, or physician assistant who will be caring for the patient in the new facility. The summary must include complete, accurate information about the following:
A written copy of the patient’s medical and social history should accompany the patient during transfer and may also be sent electronically to the receiving facility to ensure that there are no information gaps. Effective communication between staff members of institutions helps ensure continuity of care. For example, the patient’s nurse can call the receiving institution to review the information shortly before the patient is transferred and can call the nurse who will care for the patient after discharge. Click here for Patient Education Which action is appropriate when caring for an elderly client admitted to a health care facility quizlet?Which action by the nurse is appropriate when caring for an elderly client admitted to a healthcare facility? Invite a family member to join the conversation.
Which standards are important for the nurse to use in critical thinking quizlet?In critical thinking, integrity means the nurse should follow the highest standards of practice. Nurses should be honest and accept their own mistakes or inadequacies. Nurses should be open-minded and, if need arises, should question themselves. Having curiosity about the patient's condition is not part of integrity.
Which step should the nurse take to alert the risk management system after notifying the primary health care provider of a client's fall?The nurse taking care of the client informs the primary healthcare provider. What step should the nurse take to alert the risk management system? The nurse should document the incident in the occurrence report tool.
What is the priority nursing objective of the therapeutic psychiatric environment for a confused client?What is the priority nursing objective of the therapeutic psychiatric environment for a confused client? Maintain the highest level of safe, independent functioning.
|
Which action is appropriate when caring for an elderly client admitted to a health care facility?
zusammenhängende Posts
Urheberrechte © © 2024 decemle Inc.
