Health Care Assignment: Q&A Based on Case Studies on Healthy Aging

Question

Task: The following three (3) case studies are designed to demonstrate the integration of various principles of managing the care of older adults.

Each case study has two (2) questions attached.
Students are to answer all six (6) questions, remembering to include a critical analysis of the role of the nurse as relevant to the question.

Answers are expected to be around 250 words for each, to a total of 1500 words. All answers need to be written as academically structured paragraphs and supported by current, credible research with in text citations.

You are a RN working in ED, looking after Edith, an 87-year-old with an admitting diagnosis of Acopia. All acute interventions have been completed for Edith, but the wards are full, so she will spend the next 8 hours (+) on an ED trolley in a corridor.

1. What is the impact of a diagnosis based on the labeling of a patient?
2. How do normal changes of ageing increase the risk of Edith developing a pressure injury in this scenario?
You are a RN working in community care, visiting Amita, a 76-year-old with a chronic and painful venous ulcer on her lower leg. She takes multiple medications for chronic illness, and a codeine-based medication for pain. Amita lives alone in her own home.

3. How would Amita’s chronic pain impact on her ability to maintain a safe environment?
4. Why is Amita, as an older adult, more vulnerable to adverse drug events? You are a RN working on an acute medical ward, looking after Oliver, an 80-year-old with painful cellulitis from hand to shoulder from a small left hand scratch sustained while gardening. He is admitted for 7 days of QID IVABs via a right cubital fossa PIVC. Because of the cellulitis, PIVC and IVAB regime, Oliver’s mobility is limited.
5. Outline the normal changes of ageing on the respiratory system in predisposing Oliver to pneumonia during his hospital admission.
6. What are the benefits of increasing the mobility of an older adult during hospitalization? How should the RN encourage incidental exercise during Oliver’s admission?

Answer

Question 1
Labeling of a patient is often attributed to the complex dynamics of human interaction between the nurse and the patient who is the healthcare recipient in a healthcare setup. It involves certain perceptions of the nurses alongside the labels they designate for behaviors exhibited by the patient. Maintenance of professional boundaries and compliance to the standard for consistency of care for the patient on the part of the nursing professional may be helpful in providing holistic care to such labeled patients (Strudwick, 2016). Relevant literature has substantial evidence in revealing that labels of ‘Acopia’ in geriatric patients often results in otherwise reversible, undiagnosed pathology and therefore calls for comprehensive geriatric assessment so as not to undermine these factors. Preconceived concepts of the nurses and dearth of medical education for nurses in handling older patients lead to such situations where treatment get compromised due to lack of integrated and coordinated plan apart from paucity in rendering long-term follow-up for a healthy wellbeing (Dyer et al., 2018). Determination of the medical, psychological, social, environmental and functional capability of the frail, older patient through a multidimensional, interdisciplinary diagnostic approach is considered vital in this regard to prioritize healthcare for the geriatric population without any labeling. Communication of the knowledge alongside proper supervision gained on the part of the nurses regarding the link between illness and pathogenic social conditions as well as self-inflicted illness is crucial to abate the impacts of labeling of patients thereby facilitating smoother recovery and optimal outcomes for the patient (Michaelsen, 2020).

Question 2
Edith is an 87-year-old woman who has been admitted to ED upon diagnosis of Acopia. Although she has been subjected to all acute interventions upon hospitalization, yet she has to spend the next 8 hours in an ED trolley in a corridor, as the wards are full. Under such circumstances, it is quite likely for her to develop pressure injury. Her advancing age makes her more vulnerable to develop such injury thereby increasing her risk. The reason for such pressure injury may be attributed to normal changes of ageing. It has been seen that in elderly individuals, lack of mobility due to various factors predisposes them to develop pressure injury because of reduced tolerance of the person’s skin and underlying tissues to forces that cause skin damage and lowered circulation. Further tissue damage might result from pressure, friction and/or shear or a combination of all these three forces upon the skin and underlying tissues for a prolonged period thereby also leading to impaired blood supply. Moisture may also contribute to tissue injury and may result from urinary incontinence (Hommel&Santy-Tomlinson, 2018). Edith reportedly having ‘Acopia’ is likely to have suffered from inability to cope with activities of daily living (ADL) that include bathing, toileting, maintaining continence, grooming, feeding, transferring among others. Inability to perform these tasks thus accentuates the risk of developing pressure injury for Edith. Integration and coordinated services across the continuum of care for geriatric patients may aid in alleviating the ensuing situation (Donelan et al., 2019).

Question 3
Amita is a 76 year-old woman suffering from chronic and painful venous ulcer on her lower leg who lives alone at home. Pertinent research study has revealed that venous leg ulcers are the major cause of chronic leg wounds that in turn may lead to systemic illness in the end. Apart from these, venous leg ulcer is often found to carry significant morbidity among the geriatric patients. Data suggests annual prevalence to be 1.7% among people of 65 years and older (Pugliese, 2016). Thus, recurrent chronic wounds that are often difficult to heal result due to venous leg ulcer. Detailed analysis shows that chronic non-healing wounds of the lower extremities become susceptible to microbial invasion that in turn may cause serious complications, which include delayed wound healing, enlarged wound size, cellulitis, debilitating pain alongside deeper wound infections (Pugliese, 2016). Study depicts that wound infection often follows venous leg ulcer (Bui et al., 2018). Further, investigation has brought to the forefront that these venous leg ulcers that appear as lesions between knee and ankle joint result due to venous insufficiency that may culminate in development of venous hypertension (Chamanga, 2018). Therefore taking into consideration all factors that may affect directly or indirectly Amita’s chronic pain, it is important to state that the ability to maintain a safe environment will be challenged in her case. It is very likely that her mobility will be compromised owing to swelling in legs coupled with a feeling of tightness in calves thereby posing threat to her safe movement.

Question 4
The myth that substance abuse is not rampant among the older adults has been busted in recent research investigations. Deeper probe into the issue of substance abuse among older has revealed certain factors that accompany such claims. Physical symptoms like that of chronic pain in addition to social symptoms which further act as potential indicators such as social isolation due to living alone have been identified as potential indictors of substance misuse or abuse(McGovern &Sarabia, 2018). Thus, it may be said Amita who is an older adult having a history of venous leg ulcer and under codeine medications is more vulnerable to adverse drug events. Hence, the Registered Nurse should make every effort to screen for the risks through risk evaluation and mitigation strategy (REMS) in case of the concerned patient thereby minimizing the risk of harm in such instances (McGovern &Sarabia, 2018). REMS tool for opioid analgesics like that of codeine has been advised to ensure that their benefits outweigh risks of abuse or addiction (McGovern &Sarabia, 2018). Further, advanced age of Amita also predisposes her to develop age-related liver, heart, lung or kidney complication that again necessitates adjusting the dose of codeine medication and application of caution for allaying the adverse effects. Constipating effect of codeine has been documented in a relevant study that appraised codeine as an analgesic in case of older patients (Jones, 2017). Moreover, polypharmacy alongside pharmacokinetic and pharmacodynamic changes due to aging predisposes Amita to be under the ambit of adverse drug events (Kim& Parish, 2017).

Question 5
As part of the ageing process, it has been seen that the bodily systems such as that of the respiratory system undergoes certain systemic and functional changes. This results in weakening of ribs and diaphragm causing diminished ability of the chest to expand and thereby affecting the capacity of breathing. The reasons behind these may be attributed to the loss of lung tissue and halted production of alveoli during early adulthood. In addition to these, there occurs reduction in the number of lung capillaries apart from loss of elasticity because of decreased elastin within the tissues(Amarya et al., 2018). Further depletion of mass in spine and ribs leads to curvature of the spine. Thus, limitation in breathing patterns is noted owing to weakening of chest expansion under the influence of ribs and diaphragm muscles (Amarya et al., 2018). Oliver, an 80-year old man suffering from painful cellulitis has been hospitalized for 7 days and is kept under PIVC and IVAB regime. However, apart from normal process of ageing, other factors predispose Oliver to pneumonia during his hospital admission. Studies show that central venous catheters pose as risk factors for healthcare associated infection like catheter related bloodstream infection in hospitalized patients due to multiple reasons. Reasons include failure to disinfect infusion systems, frequent handling of catheter and using it to gauge the venous pressure, any underlying disease, dressing type and clinical severity (Rodríguez-Acelas et al., 2017). Hence, Oliver who is already plagued with cellulitis is under the threat of contracting pneumonia, an inflammatory lung disease due to infection.

Question 6
During hospitalization, the older adult tends to have limited mobility that interferes with his/her activities of daily living. Thus, the benefits procured from increasing the mobility of an older adult during hospitalization may be multifaceted. This would ensure the patient’s return to the pre-hospital level of functioning.It has been mentioned further that simulating the living condition at home acts as a preparatory phase for a return to independence and opening up new vistas for extended rehabilitation (Wanigatunga et al., 2019). This in turn facilitates the patient’s self-confidence in performing the tasks independently on return to home. Moreover, enhanced mobility also ensures that the patient has heightened self-esteem thereby accentuating the chances of quicker recovery (Wanigatunga et al., 2019). It has been documented in studies that incorporation of incidental exercise intervention leads to improvement in upper body strength, mobility and continence. Therefore, it is crucial for the Registered Nurse (RN) to encourage the patient to perform incidental exercise. The RN may adopt the person centered approach by respecting for as well as integration of individual differences by virtue of observing function-promoting nursing practice in fulfilling the desired objective. As aged care is one of the challenging duties for the RN, it is crucial to build a therapeutic rapport with the patient and assess properly. Upon accurate assessment, the RN has to identify the interventions and prioritize them in line with the patient’s (here Oliver’s) wishes (Su Jung et al., 2019). Working in collaboration with other healthcare professionals such a physical therapist is highly recommended to ensure optimal outcomes for Oliver.

References
Amarya, S., Singh, K., &Sabharwal, M. (2018).Ageing process and physiological changes.In Gerontology.IntechOpen.

Bui, U. T., Finlayson, K., & Edwards, H. (2018). Risk factors for infection in patients with chronic leg ulcers: A survival analysis. International Journal of Clinical Practice, 72(12), e13263.

Chamanga, E. T. (2018). Understanding venous leg ulcers. British journal of community nursing, 23(Sup9), S6-S15.

Donelan, K., Chang, Y., Berrett-Abebe, J., Spetz, J., Auerbach, D. I., Norman, L., &Buerhaus, P. I. (2019). Care management for older adults: The roles of nurses, social workers, and physicians. Health Affairs, 38(6), 941-949.

Dyer, A. H., Ryan, D., & O’Callaghan, S. (2018). ‘Acopia’and ‘inability to cope’remain unhelpful and pejorative labels for complexity in older adults presenting to the acute hospital. Age and ageing, 47(3), 488-488.

Hommel, A., &Santy-Tomlinson, J. (2018). Pressure Injury Prevention and Wound Management. In Fragility Fracture Nursing (pp. 85-94).Springer, Cham.

Jones, C. (2017). Safe sedation, codeine restrictions and NAD 17 lead media coverage. ANZCA Bulletin, 26(4), 12.

Kim, J., & Parish, A. L. (2017).Polypharmacy and medication management in older adults. Nursing Clinics, 52(3), 457-468.

McGovern, J., &Sarabia, S. (2018). Substance abuse among older adults: Context, assessment, and treatment. In New directions in treatment, education, and outreach for mental health and addiction (pp. 111-124). Springer, Cham.

Michaelsen, J. J. (2020). The'difficultpatient'phenomenon in home nursing and'self?inflicted'illness. Scandinavian journal of caring sciences.

Pugliese, D. J. (2016). Infection in venous leg ulcers: considerations for optimal management in the elderly. Drugs & aging, 33(2), 87-96.

Rodríguez-Acelas, A. L., de Abreu Almeida, M., Engelman, B., &Cañon-Montañez, W. (2017). Risk factors for health care–associated infection in hospitalized adults: systematic review and meta-analysis. American Journal of Infection Control, 45(12), e149-e156.

Strudwick, R. M. (2016). Labelling patients. Radiography, 22(1), 50-55.

Su Jung, L. E. E., Mi So, K. I. M., & You Jin, J. U. N. G. (2019). The effectiveness of function-focused care interventions in nursing homes: a systematic review. The Journal of Nursing Research, 27(1), 1.

Wanigatunga, A. A., Gill, T. M., Marsh, A. P., Hsu, F. C., Yaghjyan, L., Woods, A. J., ...&Pahor, M. (2019). Effect of Hospitalizations on Physical Activity Patterns in Mobility?Limited Older Adults. Journal of the American Geriatrics Society, 67(2), 261-268.