Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Assessment and Management of highly dependent patients prepared by Salwa Mahmoud Abd elwahab Under supervision Pr.Dr Kamilia Fouad Professor of medical surgical nursing Faculty of nursing Ain Shams university 2010 OUTLINES: Introduction Definition of highly dependent patients Definition related to highly dependent patients Chronic illness Disability Impairment Functional limitations Activities of daily living Instrumental activities of daily living Rehabilitation Adaptation Outline cont Classification of dependent patients Partial [temporary] dependent patients Complete [permanent] dependent patients Interdisciplinary team. Physicians Nurses Physiotherapist Occupational therapist Speech therapist Nutritionist dietitian Speech therapist Nutritionist dietitian Social workers Psychologists The recreational therapist The patient’s spiritual leader Nursing care plan : Assessment Functional assessment Interview Health history taking Physical examination [from the head to toes] Physical assessment [all the body systems] Nursing diagnosis : Physical problems [actual and potential] Psychosocial problems [actual and potential] Planning Implementation Evaluation Objectives : Define highly dependent patients Define [key terms] related to highly dependent patients Enumerate the etiological chronic Compare between two types of dependent patient Identify interdisciplinary team Describe factors that must be taken in nurse’s consideration when providing care for highly dependent patient Identify assessment tools used for a highly dependent patients Objectives cont : List three major nursing diagnosis for highly dependent patients Implement nursing intervention to provide quality care for highly dependent patients State several ways to evaluate whether or not intervention outcomes have been met Definition of highly dependent patient It is a state in which the individual experiences a limitation of activities for independent physical movement or when the person’s movement is restricted for medical reasons, result in secondary disabilities, these disabilities may develop in one or several body systems. Definition related to highly dependent patients Disability : The World Health Organization(2008) defines Disability as follows: "Disabilities is an umbrella term, covering impairments, activity limitations, and participation restrictions. Disabilities include : Sensory impairments (particularly hearing and vision) physical mobility impairments (from injury, chronic illness, congenital defect, or psychiatric conditions), emotional/cognitive impairments. Impairment : Is the physical or physiological cause of the limitation, whether related to disease, trauma, or birth defect that may or may not be associated with limitations. For example, a person with a visual impairment may have the limitation of needing to wear glasses. Activities of daily living: Are the basic activities usually performed in the course of a normal day in a person’s life, such as eating, toileting, dressing, bathing, or brushing the teeth. Instrumental activities of daily living :are not necessary for fundamental functioning, but they let an individual live independently in a community;(e.g)doing light housework ,preparing meals, taking medications, shopping ,using the telephone , using technology) Functional limitations : Refer to difficulties people may experience in performing activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Adaptation :The dynamic process in which the behavior and physiological mechanisms of an individual continually change to adjust to variations in living conditions. Rehabilitation : Is “the process of adaptation, or recovery, through which an individual suffering from a disabling condition, whether temporary or irreversible, regains, or attempt to regain, maximum function, independence, and restoration. It should begin at the first day a person is diagnosed with a disorder that can result or has resulted in functional limitation. Disabilities or functional limitations which leading to that the patient become highly dependent can result from stable or progressive chronic illnesses, this chronic illness include : Chronic illness e.g heart failure, End stage renal failure Musculoskeletal impairment Postural abnormalities : Congenital acquired postural abnormalities affect the efficiency of the musculoskeletal system as well as body alignment balance and appearance. Fracture of the : knee, hip, pelvis and spine. Neurological impairments: Damage to the central nervous system : damage to any voluntary movement. Multiple sclerosis (neurological condition). Stroke. Paralysis hemiparalysis, or quadriparalysis CLASSIFICATION PATIENT OF DEPENDENT Temporary (partial) dependent patient Permanent (complete) dependent patient INTERDISCIPLINARY TEAM - An interdisciplinary team : Is a group of people working together with the client to achieve goals for recovery or adaptation. This team include : Nurse Physician Physical therapist Social worker Psychologist Recreational therapist The nutritionist or dietitian Occupational therapist Speech language therapist NURSING CARE PLAN DEPENDENT PATIENTS FOR HIGHLY General assessment : When working with people highly dependent patient, you need to have excellent assessment skills. Although the entire interdisciplinary team aids in holistically assessing the client, you as a nurse are primarily responsible for documentation in several key areas. The nurse will assess patients through: Functional assessment Interview& health history taken Physical examination [from the head to toes] Physical assessment [all the body systems Psychosocial assessment. Functional assessment of the highly dependent patients : The Barthel index as shown in table measures the client’s mobility and self care status over client’s status in terms of levels of dependence or independence is rated in 10 categories of function. Each category is assessed with nurses rating from 0:15. The highest is 100 that mean the person is content. The Barthel index Functional component With help Independent 5 10 5-10 15 3. Personal toilet (wash face, comb hair, shave, & clean teeth) 0 5 4. Getting on and off toilet (handling, clothes, wipe & flush) 5 10 5. Bathing self 0 5 6. Walking on level surface 10 15 7. Ascending and descending stairs 5 10 8. Dressing (includes tying shoes, fastening fasteners) 5 10 9. Controlling bowels 5 10 10. Controlling bladder 5 10 1. Feeding 2. Moving from wheelchair to bed and return (including sitting up in bed) Katz index of Activities of daily living : From Katz, S., Ford, A.B., Moskowitz, R.W., Jackson, B.A., Jafe, M.W., & Cleveland, M.A. (2003): Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical Association, 185 (12), 914-919. Interview and history of the highly dependent patients: It is important for the nurse to get information from the patient and other members of the team. The patient’s age, condition and feeling will be great help in the prevention of complication. The question should be directed to gather information relate to: Personal data: Age, interest, type of activities encountered, social set up and relationships. Dietary habits : Type of food, preparation, amount as this would give an indication of the necessary needs of patient. Bowel habits : To help the patient cope with the new situation and prevent complications associated with bowel habits. Sleeping pattern : As well as most comfortable position and the comfort measures used usually. Recreational activities : Which are of most interest to the patient in order to provide the patient with activities that will prevent boredom and introspection. Intake of drugs : Such as heparin that might predispose to pressure sores. Physical examination for the highly dependent patient System Metabolic Assessment techniques Abnormal findings Inspection Slowed wound healing, abnormal laboratory data Inspection Muscle atrophy Anthropometric measurements (mid upper arm circumference, triceps skin fold measurement) Decreased amount of subcutaneous fat Respiratory Palpation Inspection General edema Asymmetrical chest wall movement, dyspnea, increased respiratory rate Cardiovascular Auscultation Crackles, wheezes Auscultation Orthostatic hypotension Auscultation, palpation Increased heart rate, third heart sound, weak peripheral pulses, peripheral edema Musculoskeletal Inspection, palpation Decreases ROM, erythema, diameter in calf or thigh increased Palpation Joint contracture Inspection Activity intolerance, muscle atrophy, joint contracture Skin Inspection, palpation Break in skin integrity Elimination Inspection Decreased urine output, cloudy or concentrated urine, decreased frequency of bowel movements Palpation Distended bladder and abdomen Auscultation Decreased bowel sounds Physical assessment [all the body systems] : The physical assessment of highly dependent patient that may be identified during a nursing assessment as the following: Metabolic system : When assessing metabolic functioning, the nurse uses anthropometric measurements (measures of height, weight, and skinfold thickness) to evaluate muscle atrophy. Assess fluid intake and output to determine whether a fluid imbalance exists. Monitoring laboratory data such as electrolytes, serum protein (albumin and total protein) levels, and blood urea nitrogen (BUN) aid the nurse in determining metabolic functioning. Monitoring food intake and elimination patterns will help to determine altered gastrointestinal functioning and potential metabolic problems The client’s food intake should be assessed before the tray is removed to determine the amount eaten. Nutritional imbalances can be avoided if the nurse assesses the client’s dietary patterns and food preferences early . Respiratory system A respiratory assessment should be performed at least every 2 hours for clients with restricted activity. The nurse inspects chest wall movements during the full inspiratory-expiratory cycle. If a client has an atelectatic area, chest movement may be asymmetrical. In addition, the nurse auscultates the entire lung region to identify diminished breath sounds, crackles, or wheezes. Auscultation should focus on the dependent lung fields because pulmonary secretions tend to collect in these lower regions. A complete respiratory assessment identifies the presence of secretions and can be used to determine nursing interventions necessary for optimal respiratory function. Cardiovascular system : Cardiovascular nursing assessment of highly dependent patients includes: blood pressure monitoring evaluation of apical and peripheral pulses, and observation for signs of venous stasis (e.g., edema and poor wound healing). Edema may indicate the heart’s inability to handle the increased workload. The nurse assess the venous system, because deep vein thrombosis is a hazard of restricted mobility. A dislodged thrombus, called an embolus, may travel through the circulatory system to the lungs or brain and impair circulation. Musculoskeletal system : Major musculoskeletal abnormalities that may be identified during nursing assessment include: Decreased muscle tone and strength. Loss of muscle mass, and contractures. Losses in muscle tone and muscle mass. Muscle atrophy is a common complication that arises from the lack of weight bearing found with bed rest. Assessment of ROM is important as a baseline against which later measurements can be compared to evaluate whether a loss in joint mobility has occurred. Integumentary system : The nurse must continually assess the client’s skin for breakdown and color changes such as pallor or redness. hygiene measures are performed, or elimination needs are provided for. At a minimum, assessment should occur every 2 hours. −Elimination system : The client’s elimination status should be evaluated on each shift, and total intake and output should be evaluated every 24 hours. The nurse should determine that the client is receiving the correct amount and type of fluids orally or parenterally. Inadequate intake and output or fluid and electrolyte imbalance can increase the risk for renal system impairment, ranging from recurrent infections to kidney failure. Dehydration can also increase the risk for skin breakdown, thrombus formation, respiratory infections, and constipation. Assessment of elimination status should also include the adequacy of dietary choices and the frequency and consistency of bowel movements. Accurate assessment enables the nurse to intervene before constipation and fecal impaction occur. Psychosocial assessment : Common reactions to restriction of activities include boredom, feelings of isolation, depression, and anger. The nurse should observe for changes in emotional status. Because psychosocial changes usually occur gradually, the nurse should observe the client’s behavior on a daily basis. Nursing diagnosis Respiratory system ; Risk for ineffective airway clearance. Risk for ineffective breathing pattern. Risk for impaired gas exchange Cardiovascular system : Activity intolerance related to increased cardiac workload. Risk for thrombus information Risk for Orthostatic hypotension Metabolic system : Altered nutrition less than body requirement. Altered nutrition more than body requirement. Risk for fluid volume deficit. Elimination system : Altered urinary elimination. Risk for constipation Risk for renal calculi Risk for urinary tract infection Muscskeletal system Impaired physical mobility. Activity intolrance due to fatigue Risk for muscle atrophy Integumentary system : Risk for impaired skin integrity. High risk for injury. High risk for infection. Self care deficit Psychological nursing diagnosis : Risk for Self-esteem disturbance. Risk for ineffective role performance. Risk for impaired social interaction. Risk for ineffective individual coping. Risk for ineffective family coping. Risk for sleep pattern disturbance. Risk for altered thought processes. Risk for knowledge deficit. Risk for powerlessness. Risk for hopelessness Planning: During planning the nurse synthesizes information from resources such as knowledge of the role of respiratory and physical therapy, standards such as skin care guidelines from the Agency for Health Care Policy and Research (AHCPR), protocols for clients at risk for falls, attitudes such as creativity and perseverance, and past experiences with dependent patients. Implementation: Nursing interventions related to highly dependent patient are classified into: Health promotion activities. Acute care-based implementations. Health promotion: Health promotion activities include a variety of interventions that can be divided into education, prevention and early detection. In this section exercise are emphasized. Exercise: The purpose of exercise: -To restore, maintain, or increase the strength of muscles. -To maintain, increase the flexibility of joint. -To maintain or promote the growth of bones. -To improve function of body systems Types of exercise: Passive: These exercises are carried out by the nurse, without assistance form the patient. Passive exercises will not preserve muscle mass or bone mineralization because there is no voluntary contraction, lengthening of muscle, or tension on bones. Active assistive: These exercises are performed by the patient with assistance from the nurse. Active assistive exercises encourage normal muscle function while the nurse supports the distal joint. Active: Active exercises are performed by the patient, without assistance, to increase muscle strength. Resistive: These are active exercises performed by the patient by pulling or pushing against an opposing force. Comparison between effect of exercise and effect of immobility on body system Body system Effect of immobility Effect of exercise Cardiovascular system •Increase cardiac • Increase efficiency workload •Increase risk for orthostatic hypotension •Increase risk for venous thrombosis of heart • Decrease resting heart rate& blood pressure • Increase blood flow& oxygenation of all body parts Body system Effect of immobility Effect of exercise Respiratory system •Decrease depth of •Increase depth of respiration •Decrease rate of respiration •Pooling of secretion (stasis) •Impaired gas exchange respiration •Increase respiratory rate •Increase gas exchange in alveolar •Increase rate of CO2 excretion Body system Effect of immobility Effect of exercise GIT system •Decrease appetite •Increase appetite •Altered protein metabolism •Increase intestinal •Altered digestion & tone utilization of nutrients •Difficulty in passing stools (constipation) •Diarrhea may result from a fecal impaction (accumulation of hardened feces) Body system Effect of immobility Effect of exercise Musculoskeletal system •Decreased muscle •Increase muscle tone & strength •Decreased joint mobility & flexibility •Increase risk for contracture formation efficiency •Increase coordination •Increase efficiency of nerve impulse transmission Actual patient care: Metabolic system: The dependent immobilized patient requires a highprotein, high-calorie diet with vitamin B and C supplements. Protein is needed to repair injured tissue and rebuild depleted protein stores. A high-calorie intake provides sufficient fuel to meet metabolic needs and to replace subcutaneous tissue. Supplementation with vitamin C is necessary to replace protein stores. Vitamin B complex is needed for skin integrity and wound healing. If the client is unable to eat, nutrition must be provided parenterally or enterally. Enteral feedings include delivery through a nasogastric, gastrostomy, or jejunostomy tube of high-protein, high-calorie solutions with complete requirements of vitamins, minerals, and electrolytes. •Total parenteral nutrition refers to delivery of nutritional supplements through a central or peripheral intravenous catheter. Respiratory system: Nursing interventions for the respiratory system are aimed at: Promoting expansion of the chest and lung. Preventing stasis of pulmonary secretion. Maintaining a patent airway. Promoting adequate exchange of respiratory gases. Promoting expansion of the chest and lungs: The nurse promotes chest expansion with several interventions: Changing the position of the client at least every 2 hours allows the dependent lung regions to reexpand. Reexpansion maintains the elastic recoil property of the lungs and clears the dependent lung regions of pulmonary secretions. The nurse should encourage the client to deep breathe and cough every 1 to 2 hours. Alert clients can be taught to deep breathe or yawn every hour or to use an incentive spirometer. These respiratory interventions will aid alveolar expansion and prevent atelectasis. Coughing reduces the stasis of pulmonary secretions. For unconscious clients with an artificial airway, the nurse can expand the chest and lungs by using an ambubag. Preventing stasis of pulmonary secretions: Stagnant secretions accumulating in the bronchi and lungs may lead to growth of bacteria and subsequent development of pneumonia. Stagnation of secretions can be reduced by changing the client’s position every 2 hours. The immobile client should take in minimum of 2000 ml of fluid a day, if not contraindicated, to help keep mucociliary clearance normal. In clients free from infection and with adequate hydration, pulmonary secretions will appear thin, watery, and clear. The client can easily remove the secretions with coughing. Without adequate hydration the secretions are thick and tenacious and difficult to remove. Encouraging fluids also benefits in helping with bowel and urine elimination and aids in maintaining circulation and skin integrity. Chest physiotherapy (CPT): (percussion and positioning) is an effective method for preventing pulmonary secretion stasis. CPT techniques help the client to drain secretions from specific segments of the bronchi and lungs into the trachea so that the client can cough and expel the secretions. Maintaining a patent airway: Highly dependent patient and those on bed restore generally weakened. If weakness progresses, the cough reflex gradually becomes inefficient. The stasis of secretions in the lungs may be life threatening for an immobilized client because hypostatic pneumonia can easily develop. Dislodging and mobilizing the stagnant secretions reduce the risk of pneumonia. The nurse should actively work with the client to deep breathe and cough every 1 to 2 hours. In the highly dependent patient an obstructed airway is usually a result of mucous plug. The nurse can implement several therapies, such as CPT, to reduce the risk of mucous plugs and to maintain a patent airway. Nasotracheal or orotracheal suction techniques may be sued to remove secretions in the upper airways of a client who is unable to cough productively. Cardiovascular system: The effects of bed rest or highly dependent patients on the cardiovascular system include: Orthostatic hypotension. Increased cardiac workload. Thrombus formation. N.B. Nursing therapies are designed to minimize or prevent these alterations. Reducing orthostatic hypotension: The nurse attempts to get the client moving as soon as the physical condition allows, even if this only involves dangling at the bedside or moving to a chair. Reducing cardiac workload: A primary intervention is to discourage the client from using the valsalva maneuver. When using this maneuver, the client holds his or her breath, which increases intrathoracic pressure. This decreases venous return and cardiac output. When the strain is released, venous return and cardiac output immediately increase and systolic blood pressure and pulse pressure rise. Preventing thrombus formation: Many interventions reduce the risk of thrombus formation in the immobilized client. Leg exercises, encouraging fluids, position changes, and teaching should begin when the client becomes immobile. Musculoskeletal system: The highly dependent client must receive some exercise to prevent muscle atrophy and joint contractures. If the client is unable to move part or all of the body, the nurse must perform passive ROM exercises for all immobilized joints while bathing the client and at least 2 or 3 more times a day. Elastic stockings also aid in maintaining external pressure on the muscles of the lower extremities and thus may promote venous return. ROM exercises are designed to reduce the risk of contractures but may also aid in preventing thrombi. Integumentary system: The major risk to the skin from restricted mobility is the formation of pressure ulcers. Interventions aimed at prevention are positioning, skin care, and the use of therapeutic devices to relieve pressure. The immobilized client’s position should be changed according to the client’s activity level, perceptual ability, treatment protocols, and daily routine. Although turning every 1 to 2 hours is recommended for preventing ulcers, it may also be necessary to use devices for reliving pressure. Elimination system: The nursing interventions for maintaining optimal urinary functioning are directed at keeping the client well hydrated and preventing urinary stasis, calculi, and infections without causing bladder distention. Adequate hydration (e.g., 2000 to 3000 ml of fluids per day) helps prevent renal calculi and urinary tract infections. If the client is incontinent, the nurse should modify the care plan to include toileting aids and a hygiene schedule so that the increased urinary output does not cause skin breakdown. To prevent bladder distention, the nurse assesses the frequency and amount of urinary output. The nurse must also record the frequency and consistency of bowel movements. A diet rich in fluids, fruits, vegetables, and fiber can facilitate normal peristalsis. If a client is unable to maintain regular bowel patterns, the physician may order stool softeners, cathartics, or enemas. Psychosocial changes: Responsibilities of the nurse in meeting the psychosocial needs of highly dependent patients Preventing the serious physiological consequences that prohibit the patient from regaining some degree of independence. Relating to the patient as a whole person so that she sees herself as a person of dignity and worth. Providing diversionary activity to help decrease boredom. Nurses must work with patients to explore strengths so that the patient may maintain their self esteem. Evaluation: To evaluate outcomes and response to nursing care, the nurse measures the effectiveness of all interventions. The outcomes are compared with the selected outcomes, such as the client’s ability to maintain or improve body alignment, joint mobility, walking, moving, or transferring, or to prevent the hazards of immobility or highly restricted of activities . The nurse evaluates specific interventions designed to promote body alignment, improve mobility, and protect the client from the hazards of immobility.