Elderly Care Training Manual for CHO.pdf

HEALTH M AL NATION ISSI N...

HEALTH M AL NATION ISSI N O Ministry of Health & Family Welfare Government of India Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres Contents Chapter 1: Introduction to Healthcare of Elderly 1 Chapter 2: Healthy Ageing 2 Chapter 3: Common Illnesses in Elderly 6 Chapter 4: Comprehensive Geriatric Assessment 12 Chapter 5: Basic Nursing Skills 20 Chapter 6: Health Promotion, Self-care and Counselling in Elderly 27 Chapter 7: Service Delivery Framework & Continuum of Care 46 Annexures Annexure 1: Community Based Assessment Checklist (CBAC) 50 Annexure 2: Comprehensive Geriatric Assessment Tool 54 Annexure 3: Equipments at Health and Wellness Centre 81 References 83 List of Contributors 84 Contents iii Introduction to Healthcare of Elderly 1 With increased access and advancement in health care combined with several other factors, people all over the world are now living longer than before. It is natural, therefore, that health care workers are likely to encounter older patients frequently in their practice and service. India has a large number of people now aged 60 years or more. The population over the age of 60 years has tripled in the last 50 years in India and will increase further in the near future. Old age is a sensitive phase - elderly people need care and comfort to lead a healthy life without worries and anxiety. Lack of awareness regarding the changing behavioral patterns in elderly people at home leads to abuse of them by their kin. Various issues affect the lives of senior citizens and further complicate into major physiological and psychological problems. Along with increased risk of diseases in old age, there are various other issues that lead to the downfall of the health of the old people. The elderly population have various complex needs (physical, emotional, nutritional, financial) and the inability of the younger family members to understand these needs lead to them regarding the elderly individuals as a burden. Elders suffering from cognitive challenges undergo serious personality changes; at this point, they need care and attention. When they are left unattended, most of them are gripped with overwhelming feelings of dejection, purposelessness; some of them even turn violent. The elderly suffers from multiple and chronic diseases. They need long term and constant care. Their health problems also need care from various disciplines, e.g. ophthalmology, orthopedics, psychiatry, cardiovascular, dental, urology to name a few. Thus, a model of care providing comprehensive health services to the elderly at all levels of health care delivery is imperative to meet the growing health need of the elderly. Moreover, the restricted and bed-bound elderly Introduction to Healthcare of Elderly need care close to their homes. Ayushman Bharat Health and Wellness Centers are providing healthcare service closer to the community with comprehensive approach. The expanded service packages are a part of this approach. Elderly care is an important package among these expanded services. This module would help Community Health Officers (CHO) positioned at the Sub Health Centre – Health and Wellness Centre (SHC-HWC) to offer the necessary services related to elderly care in the community. 1  Healthy Ageing 2 As per Ministry of Health & Family Welfare, citizens above the age of 60 years are considered Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres to be elderly. With socio-economic development, declining fertility and increase in survival at older ages, the proportion of older people (60 years and above) in general population has increased substantially within a relatively short period of time. India recorded a significant improvement in life expectancy at birth, which was 47 years in 1969, growing to 60 years in 1994 and 69 years in 20191.The share of population of elderly was 8% in 2015 i.e., 106 million (10 crores plus) across the nation, making India the second largest global population of elderly citizens. Further, it has been projected that by 2050 the elderly population will increase to 19%. Therefore, to identify the health needs of the elderly, it is necessary to understand ageing and age related changes. So first we will understand the process of ageing What is ageing? Ageing is a universal phenomenon comprising of gradual loss of cells leading to deterioration of organ functions in a human body. Age related alteration affects across the elderly population and their body function diminishes. Ageing is not a “disease” but the elderly population are more susceptible to various diseases due to decreased immune response and poor regenerating capacity. Healthy Ageing: Healthy Ageing is “the process of developing and maintaining the functional ability that enables wellbeing in older age”. Functional ability is about having the capabilities that enable all people to be and do what they have reason to value. 2 This includes a person’s ability to: ’’ meet their basic needs ’’ to learn, grow and make decisions ’’ to be able to roam around/be mobile ’’ to build and maintain relationships ’’ to contribute to society Functional ability of an individual is made up of the interaction between his/her intrinsic capacity and the environment in which he/she inhabits. Intrinsic capacity means all the mental and physical capacities that a person can draw on. It is as simple as their ability to walk, think, see, hear and remember. This capacity changes with the presence of diseases, injuries and age-related changes. In the elderly, the intrinsic capacity is often reduced. Environment includes the home, community and broader society, and all the factors within them. The factors are the environment, people and their relationships, attitudes and values, health and social policies, the systems that support them and the services that they implement. For elderly, it is important to have an environment where in they can feel comfortable and accepted. Being able to live in environments that support and maintain an individual’s intrinsic capacity and functional ability is key to Healthy Ageing. The environments also mean that the health system should be responsive towards the needs of elderly in the community. You, being a part of health systems, also need to be sensitive towards elderly and their health needs. Age-related changes in human body system It is important for a caregiver to understand the age-related changes in the human body which will further help in meeting their needs. What are the Signs of Ageing? ’’ Vision impairment ’’ Hearing impairment ’’ Disturbed sleep ’’ Loss of teeth ’’ Change in taste ’’ Decline in functions of lungs ’’ Decline in functions of heart ’’ Decline in functions of kidney Healthy Ageing ’’ Wrinkling of skin ’’ Decrease in muscle strength ’’ Decrease in bone strength 3 Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres ’’ Loss of bladder control ’’ Loss of appetite ’’ Decrease in sexual function ’’ Decrease in memory ’’ Increase in tiredness Health risks in older patients Various risk factors and their ill effects in elderly people have been identified. They are listed in the following table. No. Health risks in elderly Consequences 1 Nutritional deficiencies (Over or under Decreased bone mass, immune dysfunction nutrition) 2 Inadequate consumption of fibers and fruits Constipation 3 Physical inactivity and sedentary lifestyle Functional decline, loss of appetite 4 Smoking Diabetes, cancer, cardiovascular diseases, and lung diseases 5 Excessive alcohol consumption Decreased rate of metabolism, liver diseases, Cancer 6 Drug reaction and polypharmacy Decreased physical functioning, falls, orthostatic hypotension, delirium, renal failure, gastrointestinal and intracranial bleeding 7 Accidents and injuries Infections, nosocomial complications, decreased physical functioning 4 How do you assess the risk in elderly? Completion of Community Based Assessment Checklist (CBAC) is required for all elderly in the SHC-HWC area. This will be done for each village by ASHA. The section B3 is specific to elderly. B3: Elderly-specific Y/N Y/N (60 years and above) Do you feel unsteady while Do you need help from others to perform everyday standing or walking? activities such as eating, getting dressed, grooming, bathing, walking, or using the toilet? Are you suffering from any Do you forget names of your near ones or your own physical disability that restricts home address? your movement? ASHA will identify all elderly in need of Comprehensive Geriatric Assessment - CPHC if the answer to any of the questions in Part B3 of CBAC is ‘Yes’ and will refer to MPW (F/M) for further assessment. Responses will be elicited from the elderly if the person is oriented. Otherwise, responses will be taken from the first care giver. The Operational Guidelines of Elderly Care at Health and Wellness Centers envisage mobility- based classification of elderly with three main categories- 1. Mobile elderly 2. Restricted mobile elderly (mobility only with personal assistance/device) and 3. Bed-bound (assistance required in some form)/home bound elderly for any reason and those requiring palliative care or end of life care. Assessment of high risk of elderly is conducted based on mobility. Services prioritized in the order of bed bound elderly, restricted mobile elderly and mobile elderly. Healthy Ageing 5  Common Illnesses in Elderly 3 As people grow old, there are some degenerative conditions that occur. Elderly people are also Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres prone to some diseases. In this chapter, you’ll learn about a few common health problems in the elderly. Common conditions in older age include hearing loss, blurred vision/difficulty in reading, back and neck pain, diabetes, depression, and dementia. Furthermore, as people age, they are more likely to experience several conditions at the same time. 1. Eye problems ’’ Elderlypeople often start having issue with their eyesight as their age progresses. However, it is not necessary that every elderly would have weakened eyesight. ’’ Eye sight for near vision improves and distanced vision weakens. ’’ Blurred/weakened vision can limit mobility of the elderly, affect interpersonal interactions. It may be a trigger for depression. It often becomes a barrier to accessing information, increases the risk of falls and accidents, and makes driving dangerous. ’’ Uncontrolled diabetes and increased blood pressure can lead to issues related to eye sight. Let’s learn about common eye problems in elderly. a) Difficulty in seeing the objects nearby: Presbyopia ’’ This is a common complaint among elderly. ’’ It is a condition that is age related and is commonly starts after the age of 40. ’’ In presbyopia, the person is not able to view near objects properly and finds difficulty in reading. ’’ It can be easily corrected by use of spectacles. ’’ There is ready made spectacles available which provide correction for near vision. 6 b) Cataract ’’ Cataract is most common eye problem in the elderly. ’’ It is a leading cause of blindness across the world and India as well. ’’ Cataract usually causes gradual loss of sight. ’’ The pupil; black circle of eye shows chalky white or greenish-grey colour. ’’ It needs a small surgery where the damaged part (lens) is removed and replaced with new artificial lens. ’’ No other treatment like eye drops/spectacles can cure this condition. Key message regarding Cataract: 1. Cataract is normally seen in elderly people and can be a result of ageing. 2. It cannot be cured by putting some eye drops but will require eye surgery. 3. The surgery commonly involves taking out the affected lens from the eye and replacing it with a new lens so that vision can be restored normal. 4. The procedure is done under local anaesthesia so that eye surgery can be done. 5. The surgery is safe and commonly done. It should be done in a recognized hospital and NOT in the community or PHC. 6. Under National Programme for Prevention and Control of Blindness and Visual Impairment, Government eye hospitals provide free surgeries to affected persons. 7. Both eyes may get affected due to ageing. The surgery may be required in both the eyes. 2. Issues with hearing ’’ As a part of ageing, people may start gradually losing their hearing. ’’ Many of the elderly could complain about not being able to hear clearly and ask the other person to speak loudly. ’’ This condition could also bring a lot of irritation to the elderly as well as others around them. Common Illnesses in Elderly ’’ Untreated hearing loss affects communication and thus may also contribute to social isolation and loss of autonomy. ’’ Inability to hear properly is often associated with anxiety, depression. ’’ This may not be understood quickly by the family members and also could be seen as elderly person “being slow”. 7  3. Falls and fractures ’’ Elderly people are often at risk of falling. ’’ Fallingmay cause fractures of bone easily for the elderly since bones grow weaker with ageing. ’’ Caregivers should be advised to accompany elderly while walking, going for bathing, toilet etc. ’’ They should also be informed about assistive devices like walking stick, walker etc. ’’ Ifthere is any recent fall that has caused a wound or a bruise, you should notify the CHO. ’’ Falls are multifactorial. This may be due to Intrinsic and Extrinsic factors ’’ Extrinsic factors include: ƒƒ Slippery bath room ƒƒ Unsafe floor/stair case ƒƒ Poor lighting ƒƒ Unsafe kitchen Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres ƒƒ Inappropriate use of walkers & crutches ’’ Intrinsic reasons include: ƒƒ Acute illness ƒƒ Lower limb muscle weakness ƒƒ Medications like sedatives etc ƒƒ Foot problems ƒƒ Problems in vision, hearing. Cause 5 for Falls in older adults Mechanical and Recurrent falls yy Multiple comorbidities Blackouts yy Risk factors for falls yy Syncope yy Gait/balance abnormalities yy Seizure yy Visual impairment yy Arthritis yy Geriatric Giants Acute Illness yy Infection Environmental hazards yy Clutter yy Stroke yy Metabolic disturbance Falls yy Slippery Floor yy Poor lighting 8 4. Genitourinary problems ’’ Most of elderly suffer from genitourinary problems. ’’ In case of men, genitourinary problems are commonly due to enlargement of the prostate gland in old age and in women it is mainly due to weak muscles. ’’ This leads to symptoms like frequent and urgent need to urinate, difficulty in starting urination, weak urine stream, dribbling of urine and inability to completely empty the bladder. ’’ This may cause significant distress to them. These individuals must be referred to the Medical Officer for treatment. 5. Psychological problems As age advances, elderly experience psychological problems and their routine is disturbed as follows: ’’ Forgetfulness ’’ Dementia (loss of memory) ’’ Depression ’’ Age related memory loss ’’ Sleep disturbances ’’ Mood swings, etc Signs and symptoms are observed or as informed by the first care giver:  Withdrawal from social activities  Lack/excessive sleep Activities to assess memory problems in elderly ƒƒ Recall of day, date and time ƒƒ Food recall ƒƒ Practice button up shirt, calculation of money and coins in purse ƒƒ Encourage them to describe “how do they dress up” ƒƒ If literate, they may also be engaged in grocery calculation  Feelings of hopelessness and worthlessness  Loss of interest in pleasurable things  Loss of interest in food intake  Increased confusion  Neglecting personal care (grooming, bathing, clothing) Frequent incidents of irritation and agitation leading to anger outburst Falls 9  6. Oral Health Problems ’’ Majority of elderly groups suffer from poor oral health issues. ’’ Traditional methods are practiced more often by elderly for cleaning of teeth which may be inadequate to maintain oral hygiene ’’ Diseases of other parts of the body may also lead to increased risk of oral disease. ’’ Adverse side effects of some treatment may also lead to dry mouth, altered sense of taste and smell. ’’ Poor oral health results in impaired nutritional status and general health, reduced self- esteem, wellbeing and quality of life Signs and symptoms are observed or as informed by the first care giver:  Dry mouth  Tooth pain  Tooth infection  Discoloration of tooth Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres  Swelling/infection of gums  Bleeding of gums  Inability to open mouth 7. Hypertension ’’ High Blood Pressure, also known as “silent killer” remains silent and undetected unless specifically checked among the elderly. ’’ Normal range of Blood Pressure among the elderly is 140/90 mm of Hg. ’’ If undetected, high blood pressure may damage the heart, brain, kidneys and blood vessels ASHA should notify CHO if any of the following signs and symptoms are observed or as informed by the first care giver:  Complaints of headache  Increased attacks of sweating, headache and palpitations  Breathlessness  Bleeding from nose 8. Diabetes ’’ Similar to hypertension, diabetes is also termed as “silent killer” which gets detected only when it is specifically checked. ’’ Diabetes can also lead to complications like heart attack or stroke Signs and symptoms are observed or as informed by the first care giver:  Frequent urination  Increased hunger 10   Excessive thirst  Unexplained weight loss  Lack of energy  Extreme tiredness  Lack of interest  Lack of concentration  Blurred vision  Repeated or severe infection like vaginal infections  Slow healing of wounds  Impotence in men  Tingling and numbness in hands and/or feet  Foot ulcers  Pressure ulcers 9. Musculoskeletal Disorders Musculoskeletal disorders are injuries or disorders of muscles, nerves, joints, tendons, cartilages and spinal discs impairing the movement. ’’ Accounts for increased morbidity among the elderly population ’’ Timely recognition may prevent complications including falls and deformities Signs and symptoms are observed or as informed by the first care giver:  Joint Pain  Difficulty in walking/squatting  Swelling in joints  Neck pain  Back ache 10. Geriatric Syndromes ’’ Geriatric syndrome is unique to older persons with multi factorial pathophysiology ’’ It leads to high morbidity and mortality ’’ Major geriatric syndromes include: 1. Delirium 2. Dementia 3. Falls 4. Incontinence 5. Pressure ulcers 6. Immobility Falls 7. Fragility 11  Comprehensive Geriatric Assessment 4 Risk assessment Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres Completion of Community based assessment checklist (CBAC) is required for all the elderly by ASHA. The section B3 is specific to the elderly. B3: Elderly Specific (60 years and above) Y/N Y/N Do you feel unsteady while standing or Do you need help from others to perform walking? everyday activities such as eating, getting dressed, grooming, bathing, walking, or using the toilet? Are you suffering from any physical disability Do you forget names of your near ones that restricts your movement or your own home address What is Comprehensive geriatric assessment - CPHC? Comprehensive geriatric assessment (CGA)-CPHC is defined as a multi-disciplinary process where the information captured is used as a basis to plan care and treatment including short term and long-term goals, follow up and rehabilitative services. The systemic evaluation of physical health, functional status, mental and psychological health and social health factors of elderly population are evaluated by a team of health professionals. The ASHA will identify any elderly in need of comprehensive assessment if the answer to any of the questions in Part B3 of the CBAC is ‘Yes’. The preliminary assessments of these identified elderly individuals are to be done by MPW(M/F) by undertaking section 1 and 2 of CGA-CPHC. Following this, a comprehensive assessment will be done by the CHO by undertaking section 3 and 4 of CGA-CPHC. If required, the CHO will refer elderly individuals who need specialized management to the medical officer or specialist and will further undertake section 5 of CGA-CPHC. The section below will give you an idea about the comprehensive assessment of elderly individuals 12  Figure: Comprehensive Health care of Elderly Cardiovascular Risk Assessment Nutritional Ophthalmic Assessment Assessment Comprehensive Health care for elderly Oral Mental Health Assessment Assessment Non Communicable disease management In the next section we shall review the specific checklists which will form part of the CGA- CPHC Overview of Components of CGA-CPHC Section Contents under each section Person responsible for each section Section 1: Basic details A. Registration details MPW (M/F) B. Identification data of elderly person Section 2: History taking A. Chief complaints MPW (M/F) Comprehensive Geriatric Assessment B. Details of complaints C. Past medical history D. Drug history E. Consumption of addictive substance F. Nutritional history G. Family history H. Social & spiritual history I. Personal history J. Home safety environment 13  Overview of Components of CGA-CPHC Section Contents under each section Person responsible for each section Section 3: 10 Minute comprehensive A. Screening for geriatric CHO or SN at PHC screening syndromes B. Screening for other age- related problems C. Functional assessment Section 4: Physical examination A. General examination CHO or SN at PHC B. Systemic examination Section 5: Syndromic specific toolkit A. Memory loss MO at PHC for assessment of the problem B. Screening for cognitive identified in section 3 impairment C. Screening for depression D. Fall risk evaluation E. Incontinence assessment & management guide Section 6: Comprehensive Geriatric Assessment Report CHO or SN/MO at PHC Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres Comprehensive Geriatric Assessment - CPHC Section I – (To be filled by MPW-F/M) A. Registration details MPW(F/M) will update the date of first assessment and name of assessor including the designation and contact details of accessor (Details attached in Annexure 2) B. Identification data of elderly person Relevant information required for the identification of elderly who are assessed by using CGA of CPHC are recorded under this section which also includes education, financial status of the elderly and family, health insurance benefits provided by government scheme. (Details attached in Annexure 2). Section II: History Taking (To be filled by MPW-F/M) MPW(F/M) updates this section with Chief complaints including detailed collection of complaints concerning eye, ear, nose, throat, cardiovascular, gastrointestinal, genitourinary, skin, neurological, musculoskeletal, gynecological. C. Past Medical history Information regarding duration of illness, current medication with dosage which is also verified through records including completion of treatment are updated under this section. D. Drug history Current medication history including over the counter medications history, drug side effects, medicines other than allopathy are collected and updated in this section. 14  Body Mass Index (BMI) This is used as a screening tool for estimating the total body fat content in a person’s body. It is calculated by dividing a person’s weight in kilograms by his or her height in meters squared (kg/m2). BMI is calculated by measuring: Weight (kgs)- You already have a weighing scale at AB-HWC. Height (meters)- A wall-mounted stadiometer or non-stretchable tape measuring height up to 2 meters can be used. BMI can be calculated by using the formula: BMI = Weight (in kg)/Height (in meter2) By using this method, underweight, normal, overweight and obese individuals can be identified. Based on observational studies it has been suggested that the normal BMI values in Asian Indian adults to be between 18 – 22.9 kg/m2. Table 4: Classification of Overweight/Obesity by Body Mass Index in Asian Indians Weight Status BMI Range/Cut-off Underweight Less than 18.0 kg/m2 Normal 18.0-22.9 kg/m2 Overweight 23.0-24.9 kg/m2 Obesity More than or equal to 25 kg/m2 Source: Consensus Group. Consensus Statement for Diagnosis of Obesity, abdominal Obesity and the Metabolic Syndrome for Asian Indians and Recommendations for Physical Activity, Medical and Surgical Management-Misra et al, 2009. E. Consumption of addictive substances MPW(F/M) collects data regarding the type, duration and the extent of addiction by updating the quantity consumed on daily, weekly and monthly basis and duration since last consumption. F. Nutritional history This includes food intake declined and weight loss over past 3 months, mobility, psychological stress, neurological problems, BMI, calf circumference which are to be categorized as malnourished, risk for malnourishment and normal nutritional status. A set of questions are administered to understand the eating pattern. Comprehensive Geriatric Assessment G. Family history MPW(F/M) updates this section with the details of illness that the family members are undertaking treatment. H. Social and spiritual assessment Sociodemographic and Spiritual details including type of house, place of worships and information regarding meditation are updated in this section. 15  I. Personal history Information regarding habits, frequency of exercise and care giver fatigue details are updated in this section J. Home safety environment MPW(F/M) assess the extent up to which the environment is safe for the elderly. This includes trouble with lighting or stairs inside and outside the house, condition of bathroom floor, ramp at home or elderly using wheelchair and walking aids, handrails in staircase and bathroom and the provision of care giver at home. Section 3: 10-minute Comprehensive Screening (to be filled by CHO) A: Screening for geriatric syndromes An elderly undergoes screening for depression, risk of falls, urinary incontinence and memory recall B. Screen for other age-related problems Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres CHO undertakes the screening with respect to vision, hearing, change in weight, constipation and insomnia. C. Functional Assessment An elderly will be assessed based on assessment tool on activities of daily living and categorizing into dependent and independent patients. Section 4: Physical examination (to be filled by CHO) CHO undertakes physical examination including general examination, head to toe examination, systemic examination and current treatment details including drug history. General Instructions: ’’ Make the elderly subject lie down or sit on a chair. ’’ Make a preliminary examination of the general appearance of the elderly subject. ’’ Where possible, all physical measurements should be conducted in a private area. Allow the participant to select the degree of privacy. ’’ Prior to taking physical measurements, explain that you will be taking the measurements. ’’ Physical examination should focus more on specific diseases or conditions for which any curative, restorative, palliative or preventive treatment may be available. ’’ During home visit, detailed geriatric assessment must be made during the visit to the home for acquiring information pertaining to the social or environmental factors influencing the health of the person. A. General Examination: ’’ Measurement of weight: 16  ’’ Ask the elderly person to remove their footwear (shoes, slippers, sandals etc.) and socks. ’’ Then instruct him/her to step on to scale with one foot on each side of the scale and to stand still, face forward, place his/her arms on the side and wait until asked to step off. ’’ Record the weight in kilograms to one decimal point on the elderly person’s form. ’’ In case the elderly person is bedridden or unable to stand up then skip weight Measurement. ’’ Measurement of height: a) In standing position (using a stadiometer):  The elderly person should be instructed to remove footwear (such as shoes, slippers, sandals etc.) and head gear (such as hat, cap, hair clips, turban etc).  Inform the elderly person about the procedure.  Instruct the elderly person to stand on the footboard facing the healthcare worker.  Ask elderly person to stand with feet together, heels, buttocks and upper back against the vertical backboard, knees straight and arms hanging free by the side.  Instruct elderly person to look straight ahead and not to look up.  Move the head rest of the stadiometer gently down onto the head of the subject. b) Recumbent length:  This measurement requires the elderly person to lie in supine position on hard mattress.  Instruct the person to look upwards, and place one cardboard against the top of the head. Keep the right leg aligned with the elderly person’s hip. Keep another cardboard touching the sole of the elderly person’s foot. Ensure that the toes of the foot are pointing straight towards the ceiling.  If the person is unable to straighten both his legs or if the ankle joint is not incorrect position, manually assist in extending the leg as far as possible or adjust the position of the ankle.  Measure the length of the person in this position by keeping one end of the measuring tape on the inner side of the cardboard placed on the head and the other end of the tape touching the inner surface of the cardboard placed at the foot. Comprehensive Geriatric Assessment  Record the height in centimeters. Measurement of body temperature (using automated thermometer): ’’ Switch the ON button on thermometer and place in the armpit. ’’ Remove the thermometer on hearing the beeping sound after 1 minute and check reading. Measurement of respiratory rate:  Simultaneously record the respiratory rate while measuring blood pressure/pulse rate. 17   Make sure the elderly subject is comfortable.  Observe the rise and fall of the chest- these counts as one breath.  Count the number of breaths for an entire minute. Measurement of blood pressure (using automatic blood pressure monitor):  Place the right arm of the elderly person on the table with the palm facing upward.  Remove or roll up clothing on the arm.  Position the cuff above the elbow aligning the rubber tubing of the cuff with the inner part of the elbow (where brachial artery pulsation can be felt).  Wrap the cuff comfortably on to the arm and securely fasten with the Velcro. Note: The lower edge of the cuff should be placed 1.2 to 2.5 cm above the inner side of the elbow joint.  Keep the level of the cuff at the same level as the heart during measurement.  Press the START button to measure the blood pressure. Measurement of pulse rate (using automated blood pressure monitor):  Record pulse rate while measuring blood pressure using automated blood pressure Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres monitor, which is already described above. Measurement of waist circumference  Measurement should be done at the end of a normal expiration.  Ask the elderly person to relax his/her arms at the sides and measure the waist circumference using the measuring tape at the level of the midpoint between the lower part of the last rib and the top of the hip. Measurement of hip circumference  The study subject should be asked to remove clothing except for the undergarments.  Tight clothing and belts should be loosened and the pockets should be emptied.  Tape should be placed around the point with the maximum circumference over the buttocks.  The elderly subject should stand with his/her feet placed close together and measurement should be taken at the end of a normal expiration. 18  Figure depicting flow of events ASHA identifies any elderly in need of further assessment if the answer to any of the questions in Part B3 of the CBAC is ‘Yes’, and informs MPW(F/M). MPW(F/M) conducts section 1 and 2 CGA-CPHC of these identified elderly individuals which includes chief complaint, past medical history, drug history, consumption of addictive substance, nutritional history, family history, social & spiritual history, personal history, home safety environment and informs CHO. CHO conducts session 3 and 4 of CGA-CPHC of the identified elderly individuals which includes screening for geriatric syndromes, screening for other age-related problems, functional assessment, general examination systemic examination. If required, CHO refers the individual to Medical Officer for detailed assessment. Medical Officer conducts section 5 of CGA- If the individual presents to the CPHCdetailed of referred elderly individuals if the PHC directly, Staff Nurse will individual has greater than 3 red flags. conduct facility based CGA and refer to the medical officer. Comprehensive Geriatric Assessment 19  Basic Nursing Skills 5 The elderly who are bedridden would need a proper nursing care. The care givers may be Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres imparted the skills to take care of the elderly. Care of the bed-ridden patient Nursing care of bed ridden patients is quite challenging Patient may be conscious or unconscious. In a bedridden patient, the care includes: ’’ Health education of the family. ’’ Involving the family in the care. ’’ Demonstrate the care and make a follow up plan. ’’ Regular home visits. ’’ Airway clearance ’’ Adequate fluid intake (oral, nasogastric tube feeding) ’’ Bowel and bladder care ’’ Personal hygiene- head to foot care ’’ Prevention and care of pressure sores ’’ Exercise ’’ Communication ’’ Assessment of symptoms, recording and reporting. Care of hair and how to give head bath Stimulating the scalp by massage and brushing improves circulation and keeps hair healthy 20 Purpose ’’ To keep the hair clean and healthy ’’ To promote the growth of hair ’’ To prevent loss of hair ’’ To prevent itching and infection ’’ To prevent accumulation of oil, dirt and dandruff ’’ To prevent hair tangles ’’ To provide a sense of well-being ’’ To stimulate circulation ’’ To destroy lice ’’ To appear well groomed Points to remember while giving head bath ’’ Protect the bed linen and pillow cover with a towel and mackintosh. ’’ Place a mackintosh under the patient’s head and neck. Keep one end of the mackintosh in a bucket to receive the water. Wash thoroughly with soap or shampoo. ’’ Rinse thoroughly and dry the hair. Braid the hair into two on each side of the head, behind the ears to make the patient more comfortable when lying on her back. Care of eyes The most common problem of the eyes is secretions that dry on the lashes. This may need to be softened and wiped away. Each eye is cleaned from the inner to the outer corner with separate swabs 3 or 4 times daily with boiled, cooled water. Care of nose and ears Excessive collection of secretions makes the patient sniff and blow the nose. External crusted secretions can be removed with a wet cloth or a cotton applicator moistened with oil, normal saline or water. Dirt may accumulate behind the ears and in the front part of the ear. Another common problem is the collection of ear wax and when it cannot be removed, it should be referred to higher facility. Mouth care If the elderly is conscious, help them in their mouth care. If the elderly is unconscious, the care givers need to be taught mouth care by demonstrating the procedure. Solutions which can be Basic Nursing Skills used are - Normal Saline, toothbrush and tooth paste. Daily assessment is recommended. Brush and rinse mouth twice daily or according to the patient’s condition. Soak dentures overnight. Apply lip balm for cracked lips 21  Care of dependent patients ’’ 2 or 4 hourly mouth care (assess individually) ’’ Use of soft brush, foam sticks applicator or glove and gauze ’’ Use of syringe for gentle mouth wash ’’ Avoid lemon and glycerin as it causes dry mouth. Assisted oral care ’’ Explain the procedure to the patients and help them. ’’ Assemble the things needed for mouth care i.e., toothbrush, toothpaste, small basin, water in a jug, towel, lip lubricant. ’’ Put him on side lying position with a towel below the cheek. ’’ Cut short the bristles of the toothbrush and wrap with the gauze or sterile cotton cloth. ’’ Use one tsp of salt in 500ml of water and boiled ’’ Remove all the water from the mouth to prevent aspiration. Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres Bed bath Bathing is very important in maintaining and promoting hygiene. It helps: ’’ To clean the dirt from the body ’’ To increase elimination of wastes through the skin ’’ To prevent pressure sores ’’ To stimulate circulation ’’ To induce sleep ’’ To provide comfort ’’ To relieve fatigue ’’ To give the patient a sense of well-being ’’ To regulate body temperature ’’ To provide active and passive exercises General instructions for bed bath ’’ Maintain privacy ’’ Explain the procedure ’’ Patient’s room should be warm and free of draughts ’’ All needed equipment should be at hand and conveniently placed ’’ Avoid giving unnecessary exertion to the patient ’’ Remove the soap completely from the body to avoid the drying effect ’’ Only small area of the body should be exposed and bathed at a time 22  ’’ Support should be given to the joints while lifting the arms and legs during cleaning and drying of these areas ’’ Provide active and passive exercises whenever possible unless contraindicated ’’ Wash the hands and feet by immersing them in a basin of water because it promotes thorough cleaning of the fingernails and toe nails ’’ Cut short the nails, if they are long ’’ A thorough inspection of the skin especially at the back of the body should be done to find out the early signs of pressure sore ’’ All the skin surfaces should be included in the bathing process with special care in cleaning and drying the creases and folds and the bony prominences, as these parts are most likely to be injured ’’ Cleaning is done from the cleanest area to the less clean area, e.g., upper parts of the body should be cleaned before the lower parts ’’ The temperature of the water should be adjusted for the comfort of the patient ’’ Creams/oils/paraffin are used to prevent drying and excoriation of the skin ’’ Keep the patient near the edge of the bed to avoid overreaching and straining of the back of the care giver Back care ’’ Elderly, who are prone to pressure sores, must have their back care every 2 hours or more frequently ’’ Wash the back with soap and water, dried and massaged with any available lubricant to prevent friction ’’ Massaging helps to increase the blood supply to the area and prevent pressure sore ’’ Give special attention to the pressure points ’’ Dry the area by patting and not by rubbing ’’ Stroke with both hands on the back Nutrition – oral intake or Naso-gastric feeding The elderly and family must be educated about the importance of nutrition. General instructions ’’ Diet must be planned according to the needs of patient ’’ Procedures to be done at least one hour before the meals ’’ Serve the food in a good environment ’’ In a bedridden patient assemble all the things near the patient and assist if needed Basic Nursing Skills ’’ Give easily digestible food ’’ Give time to the patient to eat the food ’’ Talking to the patient while he/she is eating will make the patient feel good ’’ Before and after food give water for hand washing and oral care 23  Naso-gastric feeding is given to the patient who is not able to take orally. The following points are to be kept in mind: ’’ Give the patient fowlers position or raise the chest with extra pillows ’’ Prevent entry of air inside the tube by pinching or folding the tube and open the cap, fix the syringe (20ml or50ml). ’’ Aspirate the stomach contents and see whether the tube is in position ’’ If the aspiration fluid is more than 50ml, skip the feed ’’ Before and after feed give about 50ml of plain water ’’ Give total 200 ml of prepared feed. (Total feed plus water not to exceed more than 250 ml) ’’ Give the feed slowly without air entry ’’ After feed give oral care ’’ Keep the patient in the same position for half an hour ’’ Then put the patient on side-lying position (to drain the secretions out of the mouth and prevent aspiration) Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres ’’ Give 2 hourly feed and after 10 pm (night) just two feeds at 3 hours interval ’’ Prepare feed at home with what is available like vegetable and daal, soups, milk, water, fruit juice, rice cooked water. ’’ Before giving the feed, strain and then give the food. Active and passive exercise Exercise must be integrated into the elderly’s daily life as it prevents contractures, foot drop and wrist drop. All the joints need physiotherapy. Educate the family the importance of exercise to prevent joint stiffness. If there is no restriction or bone problems exercise can be given by the family. Pressure sores A pressure sore or pressure ulcer is an injury to the skin and tissue underneath, usually caused by unrelieved pressure. Pressure on a small area of the body can compress tiny blood vessels that normally supply tissue with oxygen and nutrients resulting in insufficient blood flow and necrosis of the area. Purpose of care With proper treatment, most pressure sores will heal. Healing depends on many things, general health and diet, relieving pressure on the sore and careful cleaning and dressing. Stages of pressure sores 1) Erythema: Skin is intact but red and does not turn white when pressure is applied 2) Breakdown of the dermis: Outer layer of the skin is broken, red and painful. 3) Full thickness skin breakdown: This involves damage or necrosis of subcutaneous tissues. 24  4) Breakdown of bone, muscle and supporting tissues: This involves deep wounds that are difficult to heal. Nursing interventions 1. Prevent pressure sore development ’’ Daily examination of pressure points and skin ’’ Daily bath ’’ Keep skin soft and moist ’’ Prevent incontinence of bowel and bladder ’’ Encourage ambulation and exercise ’’ Identify patients prone to develop pressure ulcers ’’ Change the position of the patient every two hours (in lying down position) and every hour (in sitting position) ’’ Keep the patient’s skin well lubricated to prevent cracking of the skin ’’ Provide the patient with adequate fluids and diet that is with high protein content and vitamins ’’ Encourage a balanced diet to keep tissues healthy ’’ Attend to the pressure points at least two-hourly to stimulate circulation ’’ While giving and taking bedpans, lift the patients and then only remove the bed pan to avoid the friction ’’ Provide a wrinkle free bed ’’ Use special mattresses like air or water mattresses. Avoid poorly ventilated mattress ’’ Cut fingernails short ’’ Encourage the patient to move in the bed as far as possible ’’ Change the linen when wet ’’ Educate the family members about the hygiene care of the skin and pressure sore prevention 2. Relieve the pressure ’’ Reposition every 2 hours ’’ Do not rest on hip bone directly ’’ Avoid elevation of head end of bed ’’ Use special devices to relieve pressure such as air cushions, waterbed, foam pads or pillows. Basic Nursing Skills 3. Pressure sore care ’’ Use normal saline for cleaning and irrigating the wound ’’ Remove dead tissues and scab 25  ’’ Use moist dressing material; this prevents damaging granulation tissue while changing the dressing. 4. Points to remember ’’ Maintain daily hygiene with sponge bath, shower, hair care, and shave, trim nails ’’ Maintain hygienic environment, such as clean clothing, and bed linen. ’’ Assess skin integrity, especially pressure points, in areas such as sacrum, hips, heels, ankles, ribs, vertebrae, spine, shoulders, elbows, and ears. ’’ Patient with poor mobility need change of position every 2-4 hours. ’’ Positioning of pillows ’’ Massage (attention must be paid to avoid since massage can cause tissue damage at pressure points) ’’ Pad bony prominences for protection ’’ Use waterbed or air mattress ’’ Awareness of friction and shearing forces Training Manual on Elderly Care for Community Health Officer at Ayushman Bharat – Health and Wellness Centres ’’ Education of family about care procedures 26 Health Promotion, Self-care and Counselling in Elderly 6 This chapter is divided into two sections: Part A: Health Promotion and Counselling Part B: Self Care Part A: Health Promotion and Counselling What is health promotion? ’’