Assessment Framework of Vascular Cognitive Impairment - Essay Example

?Running head: Assessment framework Assessment framework Assessment Framework Introduction This is the case of Carissa, a 79 year old elderly widow who was admitted for lower back pain, for chronic lower respiratory disease as well as for cognitive impairment. Pathophysiology of vascular cognitive impairment There may be two possible pathways to vascular cognitive impairment. One is the large vessel disease and cardioembolism and the other is the small vessel disease. The large vessel disease and cardioembolism may be caused by atherosclerosis and by subsequent artery to artery embolism or embolism from cardiogenic sources (Gilman, 2007). Either way, the result is the same for both instances with single or multiple cortical infarction. Large vessel atherosclerosis starts as fatty layers in the arteries which harden into plaque as a person gets older. The development from fatty streak or layer to an unstable plaque may start off as a response to an endothelial injury which may cause an inflammatory response (Gilman, 2007). This response starts off with inflammatory cell migration, lipid deposition, and smooth muscle cell proliferation. After which, different events occur which then cause instability of the plaque, plaque rupture, platelet aggregation, and cause the formation of thrombus – eventually leading to infarction. Infarcts in particular areas of the brain may then contribute to the cognitive impairment of the patient (Gilman, 2007). In the patient’s case, the part of her brain which is attributed to her memory has been affected, thereby causing her memory impairment, decreasing her capacity for new learning and causing her disorientation. Her other functions are intact as she is able to manage writing tasks, difficult and complex activities, as well as basic problem solving. Based on some patient’s aging processes, they also suffer from cognitive sequences which are not dependent on structural lesions in the brain (Gilman, 2007). “Such people, by virtue of their age, may be more prone to hypoperfusion injury of critical areas of the brain such as the hippocampus of the basal ganglia” (Gilman, 2007, p. 229). In this patient, her cognitive impairment may be attributed to such hypoperfusion injury. Area of concern: Total hip fracture The patient underwent hip replacement when her hips were injured by a fall. This surgical procedure is conducted in order to replace the femoral neck with a metal alloy or any other material. These are common injuries among the elderly, especially those with osteoarthritis, compromised sight, and those using drowse-inducing medications (Jackson, et.al., 2009). This type of surgery can only be carried out as an inpatient surgery with its related preoperative and postoperative processes. The patient must therefore be oriented about the surgery and the preparations he must undergo in order to ensure a successful surgery and postoperative process. Following the surgical procedure is the immediate rehabilitation in order to ensure that the patient would regain strength in his injured hips (Paul and Peterson, 2002). A major part of the surgery is walking, sitting, and standing independently. During the physical therapy sessions, the nurse is obliged to assist the therapist in ensuring that the patient is safe during the exercises and that she can later carry out these exercises with the patient even without the assistance of the therapist (Meiner, 2005). The first part of the therapy would involve the safe and proper use of the walker. It also involves the process of learning how to safely sit from a lying position, how to stand from a sitting position, and how to walk safely with the crutches or cane (Landefeld, 2004). It is also the nurse’s duty to clear the area where the patient usually walks and to ensure that there are no barriers which would trip the patient or which would block the conduct of his therapeutic activities. The nurse must also learn the different exercises which the patient can safely carry out in order to ensure a successful rehabilitative process. These processes would assist in ensuring that the patient would be able to regain her independence and mobility (Paul and Peterson, 2002). The nurse would also have to be involved in an interdisciplinary practice in the patient’s care. This practice would require her to coordinate with other health professionals in delivering health care services to the patient. This includes the process of consulting with other health professionals including the attending physician, physical therapist, occupational therapist, pharmacist, the social worker, and other nurses (Naglie, et.al., 2002). Areas relevant to the patient: 1. Skin care: pressure sores Assessment: In order to assess the patient, the Braden Scale for Predicting Pressure Score Risk was used. This tool is a standard tool which is used to evaluate the level of risk for the development of pressure ulcers among adult patients (Perry, et.al., 2007). Based on score, the following ratings may be given to the patient: 15-18 (mild risk); 13-4 (moderate risk); 10-12 (high risk); and 9 (very high risk) (Perry, et.al., 2007). In the case of Carissa, after using the Braden scale, she registered a rating of 16 which puts her at a mild risk for acquiring pressure ulcers. Preventative measures: One of the best and most effective ways of preventing pressure ulcers is to reposition the patient regularly, preferably every two hours (Sharp, et.al., 2000). This would help prevent pressure from being exerted in bony protrusions of the patient’s back through prolonged indentation and prolonged stationary position. Repositioning the patient would also allow the air to circulate around the patient’s back and prevent moisture and sweat from forming in the back area (McGowan, Montgomery, and Jolley, 2000). Another means of preventing pressure sores from forming is to keep the patient’s clothes dry at all times. This would help prevent moisture, sweat, and dirt from building at the patient’s back. Moisture and dirt serve as fodder for infection and may contribute to the formation and infection of pressure ulcers (Pancorbo-Hidalgo, et.al., 2006). Actual outcomes: The actual outcome set forth for the patient is for her to reduce her risk of pressure ulcer to non-existent. Such outcomes can be achieved because her risk for pressure ulcer is still mild and she is not completely immobile. She can actually still move about independently. This makes the goal easier to achieve. Analysis of evidence: The care given is evidence-based. Log-rolling and keeping the patient clean and dry are simple and independent nursing interventions which were easily carried out for the patient (Murray, Magazinovic, and Stacey, 2001). Different researches have proven their reliability and their efficacy in managing and reducing a patient’s risk for pressure ulcers. 2. Confusion Assessment: The Confusion Assessment Method (CAM) is an appropriate tool to use for this patient (Waszynski, et.al., 2005). The CAM is the best tool to use for assessing confusion because it includes two parts. First, is the assessment tool which screens for overall cognitive impairment; and the second part includes the four features that were established to have the best ability to distinguish delirium or reversible confusion from other types of cognitive impairment. Actions: In managing the patient’s confusion, calming music was used. Calming music can be used reduce patient’s stress and to refocus his mind towards more favourable thought and emotional processes (Remington, 2002). In the case of Carissa, she likes classical music and whenever she feels agitated, stressed, or confused, we played her favourite music and she immediately calmed down. In order to manage the patient’s confusion, we also regularly oriented Carissa as to the proper date, place, and time. Employing such tactics helped to calm her and helped her understand what was going on around her (Casarett, 2001). Actual outcomes: Based on the interventions implemented, we were able to reduce her confusion and we were able to keep her well oriented in terms of time, date, and place. As she became properly oriented in these aspects, she became less confused and less prone to agitation and stress. Analysis of evidence: The use of music is based on evidence establishing that music can calm a patient (McCaffrey and Locsin, 2004). In effect, this intervention is effective in managing a patient’s confusion and agitation, making him/her more open to the things happening around him/her. In using reorientation techniques, various evidences lend support for this practice. These studies indicate that reorienting the patient regularly helps refocus the patient’s mind and makes him less confused about his surroundings and the things that are happening around him (Mador, et.al., 2004). A less confused patient in turn is less agitated and less stressed about his situation and condition. Less confusion and stress in turn makes the patient more cooperative during the performance of interventions (Surbone, et.al., 2007). 3. Sleep and rest Assessment: In assessing the patient’s sleep and rest, the Epworth Sleepiness Scale (ESS) was used. This tool evaluates the impact of sleep issues on the patient’s daytime functions (Lack, 2004). It asks the patient the following questions: How likely are you to fall asleep in the following situations rather than just feeling tired? and If you have not done these things recently, think how they have affected you in the past. These situations include: sitting and reading, watching TV, as a car passenger for an hour without a break, lying down to rest in the afternoon, and in sitting and talking to someone (Lack, 2004). Actions: In order to facilitate the patient’s sleep and rest, we asked the patient to have an afternoon nap lasting for about an hour (Bursztyn, 2002). These naps help reenergize the patient, allowing rest periods to relax and renew her energy for the rest of the day. During these naps, we made sure that the room is dark and is free of any disturbing noises. We also avoided allowing longer naps as these would disturb her Circadian Rhythm and her night-time sleeping habits (Mathis, Seeger, and Ewert, 2003). Actual outcomes: In evaluating her actual outcomes, it is apparent that the patient now seems to be more rested and is less likely to fall asleep while carrying out her daytime activities. She also feels less tired during the day and is able to carry out her activities with more vibrancy. Analysis of evidence: There is strong evidence supporting the use of naps for elderly patients (Lotjonen, 2003). Studies have reviewed the use of this method to address sleeping issues among elderly patients and most of these studies indicate support for short naps or “siestas.” These studies support the fact that naps help reenergize the patient, making him less tired for other activities of the day. Rest and sleep are important elements of the care for this patient because it is important to ensure that she has rested sleep in order to give her the strength to remain independent in her activities of daily living (Lotjonen, 2003). End-of-life care End-of-life care refers to the type of care often administered to patients who are terminally ill. In this type of care, all interventions meant to treat the underlying disease are stopped, but the care still continues for the patient. The care however does not anymore deliver treatment and cure interventions, they are meant to make the patient comfortable in the last days of his life (National Cancer Institute, 2011). He therefore receives medications and treatments which are meant to manage pain and other symptoms like constipation, nausea, vomiting, and shortness of breath (NCI, 2011). Mental care is also administered to the patient and his family at this time – in order to help them with the grieving process. In various studies about end-of-life care, authors were able to establish that there are international differences which exist in attitudes towards end-of-life issues in the ICU. Such study was able to establish that in the international scene, there are different attitudes taken on end-of-life care. In countries where intensive care medicine is developed, physicians have more hopeful attitudes towards end-of-life care. They see it as a welcome and less stressful transition for the patient. End-of-life care is also controversial in some regard because of the inclusion, in some countries, of euthanasia in its practice (National Cancer Institute, 2011). It is also important to consider that in end-of-life care, there are various improvements to the administration of care which are still worth considering. Active treatment and comfort measures are an essential part of the patient’s care and without the appropriate measures to implement these practices, it would be difficult to achieve favourable outcomes for the patient’s care (Glare and Virik, 2001). It is also important at this stage for the nurse to counsel the patient and their families about the grieving process and their general mental status. It is important for the family members to interact with their family member and to lend their emotional support to their family member. Doing so would help reduce the patient’s anxiety, agitation, and confusion. The grieving process is a long process for most families. It is therefore important for the families to ease into the changes in their life – and to remain strong for their family member. Works Cited Bursztyn, M., Ginsberg, G., & Stessman, J. (2002). The siesta and mortality in the elderly: Effect of rest without sleep and daytime sleep duration. American Academy of Sleep Medicine, volume 25, number 2, pp. 187-191 Casarett, D., & Inouye, S. (2001). Diagnosis and Management of Delirium near the End of Life. Annals of Internal Medicine, volume 135, number 1, pp. 32-40 Gilman, S. (2007). Neurobiology of disease. Sydney: Academic Press Glare, P. & Virik, K. (2001). Can we do better in end-of-life care? The mixed management model and palliative care. Med J Aust., volume 175(10): pp. 530-3. Jackson, S. (2009). Prescribing for Elderly Patients. New South Wales: Routledge Lack, L. (2004). Insomnia Management 1. Department of Human Services, Australia. Retrieved 03 May 2011 from http://www.epdgp.org.au/PDF/Insomnia%201A%20-Sleep%20Assessment.pdf Lotjonen J, Korhonen I, Hirvonen K, et al. (2003). Automatic sleepwake and nap analysis with a new wrist worn online activity monitoring device vivago WristCare. Sleep, volume 1: pp. 86-90. Mador, J., Giles, L., Whitehead, C., Crotty, M. (2004). A randomized controlled trial of a behavior advisory service for hospitalized older patients with confusion. International Journal of Geriatric Psychiatry, volume 19, number 9, pp. 858–863 Mathis, J., Seeger, R., & Ewert, U. (2003). Excessive daytime sleepiness, crashes and driving capability. Schweizer Archive fur neurologie und psychiatrie, volume 154, number 7, pp. 329-338 Meiner, S. (2005). Gerontological Nursing. New South Wales: Elsevier Health Sciences McCaffrey, R. & Locsin, R. (2004). The effect of music listening on acute confusion and delirium in elders undergoing elective hip and knee surgery. Journal of Clinical Nursing, volume, number 13, pp. 91–96 McGowan, S., Monthomery, K., & Jolley, D. (2000). The role of sheepskins in preventing pressure ulcers in elderly orthopaedic patients. Primary Intention. Retrieved 03 May 2011 from http://m-tech.co.il/photos/uploads/primary%20intention%20article-no%20add.pdf Murray, L., Magazinovic, N., & Stacey, M. (2001). Clinical practice guidelines for the prediction and prevention of pressure ulcers. Primary Intention, volume 9(3): pp. 88-97 Naglie, G., Tansey, C., Kirkland, J., & Ogilvie-Harris, D. (2002). Interdisciplinary inpatient care for elderly people with hip fracture: a randomized controlled trial. CMAJ, volume 167 (1). National Cancer Institute (2011), End of life care: Questions and Answers. Retrieved 03 May 2011 from http://www.cancer.gov/cancertopics/factsheet/Support/end-of-life-care Pancorbo-Hidalgo, P., Garcia-Fernandez, F., Lopez, Medina, I., & Alvarez-Nieto, C. (2006). Risk assessment scales for pressure ulcer prevention: a systematic review. Journal of Advanced Nursing, volume 54, number 1, pp. 94-110 Paul, S. & Peterson, C. (2002). Interprofessional Collaboration in Occupational Therapy. New South Wales: Routledge Perry, D., Borchet, K., Boyer, L., & Chevrette, J. (2007). Health Care Protocol: Skin Safety Protocol: Risk Assessment and Prevention of Pressure Ulcers. Institute for Clinical Systems Improvement. Retrieved 03 May 2011 from http://www.icsi.org/pressure_ulcer__skin_safety_protocol__risk_and_assessment_of/pressure_ulcer__skin_safety_protocol__risk_assessment_and_prevention_of__protocol_.html Remington, R. (2002). Calming Music and Hand Massage With Agitated Elderly. Nursing Research, volume 51, number 5, pp 317-323 Sharp, C., Burr, G., Broadbent, M., Cummins, M., & Casey, H. (2000). Pressure ulcer prevention and care: A survey of current practice. Journal of Quality in Clinical Practice, volume 20, number 4, pp. 150–157 Surbone, A., Kagawa-Singer, M., Terret, C., & Baider, L. (2007). The illness trajectory of elderly cancer patients across cultures: SIOG position paper. Ann Oncol, volume 18 (4): pp. 633-638. Waszynski, C. (2001). Confusion Assessment Method (CAM). Hartford Institute for Geriatric Nursing, number 13, Retrieved 03 May 2011 from http://consultgerirn.org/uploads/File/Confusion%20Assessment%20Method%20%28CAM%29.pdf Yaguchi, A., Truog, R., Curtis, R., Luce, J., & Levy, M. (2005). International Differences in End-of-Life Attitudes in the Intensive Care Unit Results of a Survey. Arch Intern Med. volume 165: pp. 1970-1975 NURSING ASSESSMENT FRAMEWORK Date: Examiner: HEALTH HISTORY 1. Biographical Data Name: Carissa Smith Phone: Address: Date of Birth: 11/01/1931 Birthplace: AUSTRALIA Age: 80 YEARS Sex: F Marital Status: widowed Ethnic origin: Occupation: Language spoken at home: English Living arrangements: Friends and Relative Home type: Own home Financial and personal resources: Supported by family and retirement pension 2. Source and Reliability Patient herself and family 3. Reason for Seeking Care Behavioural Management Monitor behaviours Memory problems 4. Present Health or History of Present Illness Lower back pain , chronic lower respiratory disease , Cognitive impairment, IHD , R) hip replacement, Asthma , 5. Past Health General Health Medically stable Childhood Illness Nil Accidents or Injuries Nil Serious or Chronic Illness Chronic lower respiratory disease Hospitalisations Asthma , Anaemia Operations R) hip replacement, L parotid adenocarcinoma and Nodes 6. Obstetric history Gravida (Pregnancies) Term (# Term pregnancies) Pre-term (# Preterm pregnancies) Ab/Incomplete: (Abortions/Miscarriages) Children Living: Course of Pregnancy (Date delivery, length of pregnancy, and length of baby’s weight and sex. Vaginal delivery/caesarean section, complications, baby’s condition) Client doesn’t have children 7. Family History (diseases or causes of death of relatives) Specify: Heart disease: Father died of heart problem and her brother died of AMI High Blood Pressure: NIL Stroke: Sister died of stroke related problems. Diabetes: NIL Blood Disorders NIL Breast Cancer: Mother had Ca Breast Cancer (other): NIL Arthritis: NIL Allergies: NIL Obesity: NIL Alcoholism: Brother and sister Mental Illness: NIL Seizure disorder: NIL Kidney disease: NIL Tuberculosis: NIL Construct GENOGRAM and attach (as above and also describes existing social network): 8. Immunisations Influenza 28/04/2010 Pneumovax 4/04/2004 9. Health checks (self-examinations and professional screening) Asthma : yes , Diabetes : No , Cancer Breast : No , cancer Bowel : No 10. Allergies NIL 11. Current Medications Name Dose Purpose Problems Aspirin 100 mg Blood thinner High blood pressure Coloxyl with senna 2 tab Stool softener Faecal incontinence Ostelin 2 tab To keep bones strong Previous history of fracture Aricept 10 mg To help her remember Alzheimer’s disease LIFESTYLE/FUNCTIONAL ASSESSMENT 12. Typical Day/Activity Level (ADLs/IADLs) Eating: Indep , Dressing : Indep , personal hygiene : Indep Bathing self : Indep , Gait aids : Indep , Mobility : Indep , Ambulation : Indep Bowel control : Indep , Bladder control : Indep , 13. Sleep/rest Restless, inadequate 14. Nutrition/Elimination Adequate and patient can feed self from tray or table when someone puts the food within reach. 15. Relationships Patient has good relationships with others 16. Social Activities Patient sometimes not joined in the group activities . 17. Coping/Stress management Patient is stressed whenever she feels pain in her L) knee 18. Personal Habits Alcohol: 1 standard drinks when drinking Smoking: Not smoking Illicit/street drugs: NIL 19. Environment/ hazards Clients fell in the last 6 months in the laundry and then also fell outside 20. Sexual Health Nil 21. Spiritual Health Goes to church every Sunday 22. Self esteem Relatively healthy self-esteem 23. Perceptions of health Feels she will not regain her health 24. Travel Can tolerate short travels PHYSICAL EXAMINATION General survey/Mental Status Appearance: wrinkled face and skin; bright eyes; graying hair, slow uneven gait, clean and ordered appearance. Behaviour: Difficult behaviours , Memory Problem , resistance with care Cognitive functions: Cognitive impairment, capacity for new learning, able to manage writing tasks, difficult and complex tasks, Basic problem solving , disorientation Thought processes and perceptions Patient is often agitated and panicked about her symptoms. Measurement Weight: 59kg Height: 171cm Body Mass Index: Vital Signs: Temperature: 36.5 Pulse: 77 Regular Respirations: 20 Blood Pressure: 125/70 Pain Assessment: 5 out of 10 in the Visual Analogue Scale EXAMINATION OF: NEUROLOGICAL AND SENSORY SYSTEMS 90% deaf in the R) Ear, decline hearing aids. Very deaf CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEMS Nil complaints of chest pain or palpitations. RESPIRATORY SYSTEM : Asthma and wheezing HAEMATOLOGICAL AND LYMPHATIC SYSTEMS Left neck hard nodes and 3 spots GASTROINTESTINAL AND HEPATIC SYSTEMS Nausea, vomiting GENITOURINARY AND REPRODUCTIVE SYSTEMS pain with urination MUSCULOSKELETAL SYSTEM R) hip replacement Lumbar back pain ENDOCRINE SYSTEM Denies history of thyroid problems IMMUNOLOGICAL SYSTEM NIL INTEGUMENTARY Small scab on the (L) shin with no other skin abnormalities appreciated. Read More