Holistic Assessment and Care Planning PDF

**HOLISTIC ASSESSMENT AND CARE PLANNING** **Holistic** - **Pertains to the whole person; body, mind and spirit** **Presence** - **Being totally " with " or engaged with another individual** - **Surviving old age is a tremendous accomplishment.** - **Basic Life requirements such as obta...

**HOLISTIC ASSESSMENT AND CARE PLANNING** **Holistic** - **Pertains to the whole person; body, mind and spirit** **Presence** - **Being totally " with " or engaged with another individual** - **Surviving old age is a tremendous accomplishment.** - **Basic Life requirements such as obtaining adequate nutrition, keeping oneself actively safe and maintaining the body's normal functions have been met with some success to survive to this time.** - **Older adults have confronted and overcome to varying degrees the hurdles of coping with crises, adjusting to change and learning new skills.** - **Throughout their lives, older individuals have faced any important decisions.** **[Key concepts]** **-Older individuals have had to be strong and resourceful to navigate the stormy waters of life.** **-NURSES should not overlook these strengths when planning care for older adults.** **-Gerontological nurses help older individuals achieve a sense of wholeness:** - **By guiding them in understanding and finding meaning and purpose in life.** - **Facilitating harmony of the mind, body and spirit.** - **Mobilizing their internal and external resources** - **Promoting self -- care behaviors.** **HOLISTIC GERONTOLOGICAL CARE** **HOLISM** - Refers to the integration of the biologic, psychological, social and spiritual dimensions of an individual in which the synergy creates a sum that is greater than its parts. - In this framework, ***HEALING THE WHOLE PERSON*** is the goal of nursing. - Incorporate knowledge and skills from a variety of disciplines to address the physical, mental, social and spiritual health of individuals. **Holistic Gerontological care is concerned with:** - Facilitating growth toward wholeness - Promoting recovery and learning from an illness. - Maximizing quality of life when one possesses an incurable illness or disability. - Providing peace, comfort and dignity as death is approached. \> **In holistic care, the goal is *not to treat diseases but to serve the needs of the total person through the healing of the body, mind and spirit.*** - Health promotion and healing through a balance of body, mind and spirit of individuals are at the core of holistic care. - The impact of age related changes and the effects of highly prevalent chronic conditions can easily threaten the well- being of the body, mind and spirit. - Therefore, nursing interventions to reduce such threats are essential. - Because chronic diseases and the effects of advanced age cannot be eliminated, **[HEALING]** rather than curative efforts will be most beneficial in gerontological nursing practice. **HOLISTIC ASSESSMENT OF NEEDS** ***HEALTH PROMOTION -- RELATED NEEDS*** 1\. Physiological balance 2\. Connection 3\. Gratification ***Physiological Balance -- sustains life if maintained*** - Should sustain basic life needs such as: - Breathing - Eating - Eliminating - Resting - Being active - Protecting oneself from risks - ***Yet by reality, even if physiological needs are satisfied, yet still not feel well, so physiological balance is only a component of an overall health.*** ***CONNECTION*** \- Connection with others, higher power, a nature and ourselves are important factors influencing health. ***GRATIFICATION*** \- The fulfillment of physiological needs and a sense of being connected promote well -- being of the body, mind and spirit that enables an older person to experience gratification through achieving : - Purpose - Pleasure - dignity ***HEALTH PROMOTION -- RELATED NEEDS*** - Using such model, Health is understood as a *"state of wholeness... an integration of body, mind and spirit to achieve the highest possible quality of life* "of each older person. - Views of health differ not only from individual to individual but also within the same individual from one time to another. - Optimal health of older adults rests on the degree to which the needs for physiological balance, connection and gratification are satisfied. - As advocates for older adults, gerontological nurses must assure that comprehensive care is provided by not omitting these important needs. **Health Challenges -- Related needs** - **Education** - As individuals face a new diagnosis, they need to understand the condition and its care. - **Counseling** - A health condition can trigger a variety of feelings and impose lifestyle adjustments. - **Coaching** - Through health education, patients can also benefit from one's efforts to improve compliance and motivation. - **Monitoring** \- The complexities of health care and the changing status of aging people warrant oversight from the nurse who can track progress and needs of patients. - Coordination -Older adults with a health condition often visit several health care providers; assistance with scheduling appointments, following multiple instructions, keeping all members of the team informed, and preventing conflicting treatments are often needed. - Therapies \- Often health conditions are accompanied by the need for medications, exercises, special diets and procedures. These therapies can include conventional treatment such as: = biofeedback = herbal remedies = acupressure = yoga \> Patients may need assistance as they implement these treatments. - **Advocacy** -There are times when older adults may need support or interception with an issue. This could involve a NURSE encouraging an older adult to express her objection to a treatment that the physician and her family are pressuring her to accept. **Requisites to meet needs** - **Physical, mental and socio economic abilities** - **Knowledge, experience and skills** - **Desire and decision to take action** ***Physical, mental and socio economic abilities***[\ ]- an individual relies on several factors to meet even the most basic life demands.\ - for example, to normally fulfill nutritional needs , a person must have the: \> ability to experience hunger sensations,\ \> proper cognition on how to select, prepare and consume food\ \> a functional digestive tract to utilize ingested food\ \> good teeth to chew food\ \> energy to shop and prepare food\ \> have the funds to purchase food ***Knowledge, experience and skills*** - Limitations exist when the knowledge, experience and skills required for a given self care action are inadequate or non existent. - Example : - People who have knowledge of the hazards of cigarette smoking will be more capable of protecting themselves from health risks associated with this habit. - An older man who is widowed may not able to cook and provide adequate diet for himself having always depended on his wife for meal preparation. - An individual with social skills is capable of a normal, active life that includes friendship and other social interactions. \> Nurse should enhance self-care abilities for older persons. ***Desire and decision to take action*** Influencing factors on the decision and desires for action: - The value of a person sees in performing the action - person's knowledge, attitudes , beliefs - degree of motivation = limitations result if a person lacks desire or decides against action = Example: \> The dying individual who views death as a natural process may decide against medical intervention to sustain life and may not comply with the prescribed therapies. Values, attitudes and beliefs are deeply established and not easily altered in a person. - Although the nurse should respect the rights of individuals to make decisions affecting their lives, if limitations restrict their ability to meet self-care demands, the NURSE can help by : = explaining the benefit of a particular action = providing information = motivating \> In some circumstances, as with an emotionally ill or mentally incompetent person, desires and decisions may have to be superseded by professional judgments. **Gerontological Nursing Process** - - - **NURSING INTERVENTIONS** -- are directed toward empowering the older individual by: - - - - - - - - - In **GERIATRIC NURSING** -- consideration must be given to assessing the impact of the health challenge on the **[person's self - care capacity]** and [**identifying appropriate nursing interventions**] to ensure that the needs related to health promotion and the management of health challenges -- related needs are met adequately. - During the ASSESSMENT, the nurse identifies the specific health challenges -- related needs that are present and the requisites (Ex. Physical capability, knowledge and desire ) that need to be addressed to strengthen **[SELF - CARE CAPACITY ]** - It is significant that interventions include those actions that can empower the older individual to achieve maximum SELF -- CARE in regards to health challenges -- related needs. **The Nurse as a Healer** - **NURSES are not merely task doers but important instruments of their patient's healing process.** - **Healing as an art is characterized by the nurse offering comfort, compassion, support and caring -- factors that were equally important to patient's healing than the procedures of caregiving.** - **The nurse serves as a healer whose interactions assist the patient in returning to wholeness, meaning optimal function and harmony among body, mind and spirit.** - **NURSES who support holism and healing do not sit on the sidelines as observers ;** - **Nurses actively engage in patients' healing processes.** - **Nurses actively engage in the patient's healing like :** - **Teaching** - **Modeling** - **Coaching** - **Encouraging** - **Helping the patient** **Healing Characteristics of Nurses** Characteristics that enables the nurses to engage as healers for older persons include: - Presence - Availability - Willingness to form connections - Models of holism ***Presence*** \- The ability to be present. Even with the unending task of nurses, NURSE healers are able to protect their interactions with patients from distractions. - When with patients, NURSES : - Are with the patient, giving their full undivided attention - Actively listen, hear what patients are saying and not saying - Uses their senses to detect subtle clues about patient's needs. \- Even if the time spent with patients is brief, the time fully belongs to the patients. Healing Characteristics of Nurses ***Availability*** - Nurse healers display availability of body, mind and spirit. - Nurses provide time and space for patients to express, explore and experience. - "That's my job" are words seldom heard from nurse healers. - For example, a patient recovering from a surgery confides to the nurse that he is distressed at learning that his grandchild was arrested for drug possession. The nurse responded " this must be difficult for you " is helpful in conveying openness and interest to let the patients express more on his feelings. Healing Characteristics of Nurses ***Willingness to form connections*** - Nurse healers : \> form connections with their patients. - engage with patients in meaningful ways that require openness, respect, acceptance and a non judgmental attitude. - commit to learning about what makes each patient a unique individual, their life journeys and the life stories they have. - May offer insights from their own life journeys and share some chapters of their lives - Exploring the unique threads that have been woven into the tapestry of a patient's life facilitates CONNECTION. ***Models of holism*** - Effective nurse healers are models of holism, which begins with self -- care practices. - Nurses not only need to eat a proper diet, exercise, obtain adequate rest and follow other positive health practices. - They also are attend to their own emotional and spiritual well-being. - Integrity demands that NURSES know what they want others to know and behave as they want others to behave. - Self -- care also is essential to performing any other role as a nurse healer. **Common Geriatric Syndromes and its Management** **Definition of Geriatric Syndrome:** - Collection of symptoms not specifically related to a disease - Occurring in vulnerable, and older adults - Multifactorial in cause - Precipitated by a variety of acute insults - Typically episodic in nature - often followed by a functional decline or disability **Common Geriatric Syndromes** - Risk for Falls - Frailty - Sarcopenia - Risk for Malnutrition - Alzheimer's disease - Constipation - Eye disorders - Urinary Incontinence - Sleep Disorder **Prevalence** - Chronic conditions and geriatric syndromes are as prevalent among older adults - Chronic conditions and geriatric syndromes are strongly associated with functional decline **Risk for fall** - A fall is considered to have occurred when a person comes to rest inadvertently on the ground or a lower level. - One of the significant concerns for safety among older adults are incidence of falls. - Falls are the leading cause of fatal and non fatal injuries in the older population. - Even if no physical injury occurs, fall victims may develop a fear of falling again and reduce their activities as a result, leads to: - *Unnecessary dependency* - *Loss of function* - *Decreased socialization* - *Poor quality of life* - A history of falls can predict a patient's future falls. - Therefore, NURSES should carefully assess persons who have experienced a fall or even a minor stumble to identify factors that may increase their risk of their problem. ***Causes of FALLS*** **INTRINSIC FACTORS** - Sensory Impairment - Gait, Balance and Mobility Problems - Medical Conditions- postural hypotension, paralysis, ataxia etc. - urinary frequency and Incontinence - Medications -- that causes dizziness and drowsiness - Behaviorial Problems - unsafe clothing -- poor fitting shoes & socks **EXTRINSIC FACTORS** **Environmental hazards:** \- Clutter in the environment \- Slippery Floors \- Dark Passages \- Waxed floors **Caregiver related factors:** - Lack of Restraints to Prevent Falls - Lack or improper use of Mobility Aids - Delays in responding to patient's request - Unsafe practices - Poor supervision of problem behaviors ***Assessment of Falls*** - Comprehensive Geriatric Assessment - ***Fall Risk Assessment Tool*** - to identify those moderate to high risk for falls - Once Identified, the patient is tagged - Interventions are prescribed - Fall Risk Assessment is done every 6 months Refer to attached article about FRAT -- Falls Risk Assessment Tool ***Interventions for Falls*** **PATIENT --CENTERED** - Treatment of Medical Problems Causing Falls - Physical Therapy - Review Medications - Patient Education - Treat the Dementia - Gait Training - Balance Exercises - Sleep Restriction **ENVIRONMENT-CENTERED** - Clutter-Free Environment - Fall Prevention Programs - Caregiver Education, Orientation and Training - Investigation and Monitoring of Falls and Corrective Actions - Providing Incentives to Fall-Free Centers - Use of Protective Devices **Frailty** - is defined as a reduced physiologic reserve vulnerable to external stressors. For older individuals, frailty plays a decisive role in increasing adverse health outcomes in most clinical situations. - A condition in which at least 3 of the following **5 symptoms are present:** - Weakness - Slow walking speed - Low level of physical activity - Unintentional Weight Loss - Exhaustion The strongest predictors are *[low level of physical activity and slow walking speed.]* - Considering that frailty is a common feature of the elderly. - Factors, such as age and malnutrition, increase the risk of frailty , but individual deviations may be great, and the level of frailty may vary. - Physical frailty in the elderly is a complex condition and the musculoskeletal aging phenotype comprises four key elements: 1. Osteoporosis 2. Osteoarthritis 3. sarcopenia 4. frailty   Possible strategies to prevent frailty include: - lifestyle/behavioral factors - proper nutrition - cognitive health maintenance. **Sarcopenia** \- A syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life and death. \- **Lack of activity** is the most common reason behind this condition. Therefore, being physically active may lessen your chances of getting sarcopenia. **Causes of Sarcopenia** **Symptoms** - People with sarcopenia often experience: - weakness - lose stamina. \> This can affect their ability to carry out physical activities. A reduction in activity then leads to further ***muscle mass loss.*** **Criteria on the Diagnosis of Sarcopenia** - Diagnosis is based on documentation of criterion 1 plus (criterion 2 or criterion 3) 1\. Low muscle mass 2\. Low muscle strength 3\. Low physical performance **Categories by Cause** - Primary sarcopenia - Secondary sarcopenia **\ Interventions for Sarcopenia** **1. Nutrition** -- Protein Supplementation = help older adults reduce their chance of sarcopenia. **2. Supplements** - have also proven   in the prevention of sarcopenia. Some include: - Creatine- for increasing and maintaining muscle mass - vitamin D- for maintaining bone and muscle tissues - whey protein- to help preserve body mass **3. Exercise** \- The main treatment path for sarcopenia is exercise. - Resistance Training - as the specific form of exercise that is most beneficial to people with sarcopenia. - This training is designed to improve muscle strength and stamina and uses resistance bands or weights. - can also help balance your hormone levels. It's been shown to improve the ability to turn protein into energy in older people. \> Combined aerobic, resistance, flexibility and/or balance training **4. Hormone replacement therapy (HRT)** = HRT can help to - raise lean body mass - decrease abdominal fat - prevent bone deterioration in women whose hormone levels decrease with menopause. = However, the use of HRT is debated because of an increased risk of some cancers and other severe health conditions. **Cachexia** - ('cac' or bad + 'hexis' or condition) - is widely recognized in older adults as severe wasting accompanying disease states such as cancer, congestive cardiomyopathy and end stage renal disease - Frequently associated with inflammation, insulin resistance, anorexia and increased breakdown of muscle proteins - is a "wasting" disorder that causes extreme weight loss and muscle wasting, and can include loss of body fat. - The difference between cachexia and other types of weight loss is that it's **involuntary**. - People lose weight because they eat less due to a variety of reasons and their their metabolism changes, which causes their body to break down too much muscle. - Inflammation and substances created by tumors can affect appetite and cause the body to burn calories more quickly than usual. - Researchers believe that cachexia is part of the body's response to fighting disease. **Three main categories of cachexia:** - **Precachexia -**  is defined as a loss of up to 5 percent of your body weight while having a known illness or disease. It's accompanied by appetite loss, inflammation, and changes in metabolism. - **Cachexia **is a loss of more than 5 percent of your body weight over 12 months or less, when you're not trying to lose weight and you have a known illness or disease. *Several other criteria include loss of muscle strength, decreased appetite, fatigue, and inflammation.* - **Refractory cachexia **applies to individuals with cancer. It is weight loss, muscle loss, loss of function, plus a failure to respond to cancer treatment. **Symptoms** - People with cachexia lose weight and muscle mass. Some people look malnourished. Others appear to be at a normal weight. - To be diagnosed with cachexia, you must have lost at least 5 percent of your body weight within the last 12 months or less, and have a known illness or disease. *[You also must have at least three of these findings:]* - reduced muscle strength - fatigue - appetite loss (anorexia) - low fat-free mass index (a calculation based on your weight, body fat, and height) - high levels of inflammation identified by blood tests - anemia (low red blood cells) - low levels of the protein, albumin **Treatment for cachexia** - There is no specific treatment or way to reverse cachexia. *The goal of treatment is to improve symptoms and quality of life.* - Current therapy for cachexia includes: - appetite stimulants such as megestrol acetate (Megace) - drugs, such as dronabinol (Marinol)- to improve nausea, appetite, and mood - medications that decrease inflammation - diet changes, nutritional supplements - adapted exercise **Malnutrition** - A healthy nutritional status has a significant impact on the mental and physical health. - In advanced age, nutritional needs are altered by factors such as: - Reduced basal metabolic rate - Decreased activity - Reduction in lean body mass with an increase in adipose tissues. - A potential and serious threat to older people so it should be closely monitored. - Contributing Factors of Malnutrition among older persons: 1. Decreased taste and smell sensations 2. Reduced mastication capability 3. Slower peristalsis 4. Decreased hunger contractions 5. Reduced gastric secretions 6. Less absorption of nutrients due to reduced intestinal blood flow 7. Decrease in cells of the intestinal absorbing surface **Nutrition Care Pathway among older persons** Step 1. Nutrition Screening Goal: nutrition screening is the key to early identification of patients at risk for malnutrition. - Initial nutrition screening or assessment is encouraged for all patients - Malnourished, and/or at-risk patients will go on to a more thorough nutrition assessment Step 2. Nutrition Assessment - Patients identified as malnourished or at-risk in the nutrition screening should be evaluated for: \* History \* Clinical exam \* Laboratory values \* Based on the results of the nutrition assessment, a tailored nutrition care plan is developed for nutrition intervention Step 3. Nutrition Intervention Potential nutrition intervention strategies: \- Alter diet prescription/diet order \- Liberalize diet \- Food fortification \- Provide food/meal preferences -Recommend vitamin/mineral supplement \- Oral Nutritional Supplements (ONS) \- Enteral Nutrition \- Parenteral Nutrition **Cognitive Impairment** **Alzheimer's Disease** - The earliest is a peculiar personality change involving lack of initiative and affect. Then come impaired recall of recent events, loss of mental functions, poor attention, confusion, loss of concentration, judgment, senseless repetitions, depression, suspiciousness... - When it starts it progresses in a downhill fashion, leading relentlessly to devastating disability and infirmity **Non -- modifiable risk factors of Alzheimer's disease:** \- Age --doubles every 5 years after 65 -- 50% greater risk after 85 yrs \- ApoE gene \--increases the risk for AD at all ages \- First-degree relatives have a 15-39% risk \- Gender -- women **Modifiable Risk Factors** = Vascular risk factors : DM, hypertension, obesity hypercholesterolemia, smoking = Midlife hypertension, dyslipidemia and obesity (\