Pressure Ulcers in Acutely Ill Elderly Patients
1. Loss of functional abilities makes the caring of elderly a difficult activity. Elizabeth’s case is worse because the case shows that all acute interventions have been completed for Elizabeth, but the hospital is bed-blocked, so Elizabeth will spend the next 8 hours (+) on an ED trolley in a corridor. Two characteristics of the acutely ill elderly patient are the decrease in their functional reserve and the decrease in the ability to adapt to an unfamiliar environment. These characteristics make the elderly patient at risk of complications and a progressive functional disability, requiring special needs for care (Kingston, Davies, Collerton et al. 2014).
The immobilization of some hours can quickly lead to the appearance of pressure ulcers and accelerates in cases of incontinence. In addition, admission is likely to bring confusion to Elizabeth. The elderly by various physiological changes and decreased sensory impulse is prone to the appearance of confusion. During hospitalization several factors coexist that are going to lead to confusion, even in normal patients, being in an unknown place, with unknown people, probably in a room with poor lighting, without any known object, without their glasses and hearing aids.
Urinary incontinence increases in hospitalized elderly people, often due to the difficulty they have during hospitalization to implement their usual strategies to avoid incontinence, the non-familiar environment, the high beds that intimidate them. They make it difficult to mobilize, to which is added the use of psychotropic drugs that reduce the perception of the need to evacuate.
2. Elizabeth, owing to the fact that she is aged 87, have risk factors for the development of pressure ulcers, which are intrinsic and extrinsic. The former is related to physical and physiological characteristics and depend on the level of resistance to immobility, alterations of breathing and circulation, predisposition to diseases, malnutrition and dehydration, which affect the structural components or tissue perfusion; and extrinsic, which are substances to which the individual is exposed, moisture conditions and room temperature, and the nature of the support surface (In Theou & In Rockwood, 2015).
Elizabeth is fragile. The fragility of aging associated with morbid conditions such as alterations in the neurological and mental state, in the nutritional status, mobility, in the activity and intestinal and urinary functions, are characteristic of a population prone to the formation of pressure area.
Elizabeth also have poor sensory perception. The multicausality of pressure area is also associated with the alterations in sensory perception – due to the use of continuous use medications, such as neuroleptics / psychotropic drugs that cause moisture compromise and the appearance of friction and deformations (Mangin, Heath & Jamoulle 2012). Poor sensory perception reduces the flow of blood and hence increasing the formation of pressure areas.
Age-Related Risks and Poor Sensory Perception in Pressure Ulcers
Elizabeth should be constantly oriented on the importance and measures for pressure relief, reviewing and implementing simple procedures such as changing position, correct use of the sheet, position in chairs and bed, prevention of friction during movements, control of humidity as well as ease and stimulation in food and hydration.
You are a RN working in a General Practitioner surgery, completing a chronic disease management plan for Pradip. Pradip is 66 year old man with multiple chronic diseases, multiple specialists and multiple prescriptions.
3. One of the factors that makes an older adult more vulnerable to drug interaction is the slow metabolism Maher, Hanlon & Hajjar 2014). For example, the induction of drug metabolism by cytochrome P-450 (CYP-450) by some drugs (eg, phenytoin, carbamazepine, rifampicin) may be decreased in the elderly patient; therefore, the change (increase) in the metabolism of a drug may be less pronounced in the elderly (Halvorsen, Granas, Engeland & Ruths 2012). Older people generally use more drugs, so they are at higher risk for multiple CYP-450 interactions that are difficult to predict. (Halvorsen, Granas, Engeland & Ruths 2012).
Elderly have less efficient organs. The liver and kidney, the two organs responsible for the degradation and elimination of drugs, are less effective with age (Halvorsen, Granas, Engeland & Ruths 2012). As a result, the chemical molecules stay longer in the blood and tissues before being eliminated, and may accumulate over time. Well-tolerated doses by young people can cause toxic effects in older people.
In addition, the drugs are distributed differently in the body of the elderly. In fact, the muscle mass and the water contained in the body diminish with age, while the fat mass increases. As a result, drugs that dissolve in water (so-called water-soluble) will see their concentrations (and therefore their effects) increased in the blood, while fat-soluble drugs will be stored in fatty tissues. Undernutrition and dehydration are common among older people. They increase the concentration and toxic effects of drugs (In Pilotto & In Martin, 2018).
4. Having one pharmacist will reduce inappropriate dosing or duration of treatment, a combination of drugs with the same effect, and possible drug-drug interactions. One pharmacy will also reduce cases of polypharmacy and poor communication (Barnett, Mercer, Norbury, Watt, Wyke & Guthrie 2012). Poor communication of medical information (from one health facility to another) causes up to 50% of medication errors and up to 20% of adverse drug effects in the hospital. Poor communication often occurs if the same patient is asked to seek drugs from different pharmacists. This is because at the end of the medical consultation, the patient often goes to a pharmacy to get his treatment delivered. Most of the time, physician-pharmacist communication essentially involves the basic rules governing the drafting of a medical prescription. If there are more than two pharmacists, each pharmacist will work independently without asking the patient whether he or she uses other drugs. In process, two pharmacists may administer the same drugs because they are ignorant about the different prescriptions (Smith, Soubhi & Fortin M et al. 2012).
Preventing Pressure Ulcers in Elderly Patients
The doctor-pharmacist tandem must be particularly active in situations of polypharmacy, polymorphism and dependence (In Nickel, In Bellou & In Conroy, 2018). The pharmacist, through its accessibility and its place in the chain of care, is a central player in prevention and participation in the management of drug treatment, especially for chronic diseases
You are a RN working in community care, visiting Arlinda, a 74 year old female with a chronic and painful venous ulcer on her lower leg. Arlinda lives alone in her own home.
5. The impact of chronic pain can quickly be catastrophic for the elderly patient, who, in most cases, will not be able to perform the acts of daily life, and who may have problems with sleep, appetite, falls, mobilization difficulties. Chronic pain may cause depression (In Nickel, In Bellou & In Conroy, 2018). The prevalence of depression is increased at least two to three times in patients with chronic pain compared to other consulting populations. The close interplay between pain and depression has been observed for a long time both in terms of clinical symptomatology and neurobiological aspects. Chronic pain can also cause anxiety (Kingston, Davies, Collerton et al. 2014). The presence of an anxiety state is associated with a very significant increase in general physical complaints, including the neurovegetative register, sleep disorders, as well as an increase in painful complaints and frequency of consultations. Indeed, in many cases, pain involves changes and losses requiring comprehensive care with contextualized drug treatments (Barnett, Mercer, Norbury, Watt, Wyke & Guthrie 2012). Other consequences include malnutrition, cognitive deterioration, alterations in the sleep-wake cycle, functional alterations, decreased socialization and leisure activities (Reuben & Tinetti 2012). All this leads to an increase in healthcare costs and a substantial reduction in the quality of life. At the level of postoperative pain, pain that is not adequately controlled is related to longer hospital stays, increased time for ambulation and chronic functional deterioration, which indicates that pain has a more powerful impact than simple discomfort (Payne, Abel, Guthrie et al. 2013).
6. The skin and immune cells participate in the process, which begins with the successful formation of a scab (Calderon-Larranaga, Vetrano , Onder G et al. 2016). Underneath, new skin cells, called keratinocytes, begin to arrive to fill the wound under the crust. In addition, these cells warn immune cells, through the production of a protein known as Skint, to stay close to the wound and thus prevent the entry of potentially harmful microorganisms into the wound. Arlinda’s wound healing can occur faster if the central nervous system communicates with the required molecules responsible for immunity. However, normal aging may hinder this process. It is important to note that both the central nervous system and the peripheral nervous system are affected by age (Calderon-Larranaga, Vetrano , Onder G et al. 2016). These systems become less effective. In the days after an injury, skin cells migrate to the wound to close it, in coordination with nearby immune cells. Both the skin cells and the immune cells participate in this complex process that begins with the formation of a scab and in which, later, the so-called keratinocytes come to regenerate the damaged tissue under the wound. Researchers at the University of Rockefeller shows that in the older mice the keratinocytes took much longer to reach the wound under the scab, which makes it take more days to close (Yeoh, Si & Chew 2013). However, since the central nervous system and peripheral nervous system are slow, the communication would be negatively affected and the healing process will take time.
Drug Interactions in Older Adults
You are a RN working on an acute medical ward, looking after Monty, a 80 year old with cellulitis on his upper arm from a small scratch sustained while gardening.
7. The physiological aging of the lungs is associated with dilation of the alveoli, increase in the size of the air spaces, decrease in the surface of the gas exchange and loss of supporting tissue of the airways. These changes produce a decrease in the elastic recoil of the lung, with an increase in volume and functional residual capacity. The distensibility of the thoracic cage decreases which increases the respiratory work when compared with young people. With age, the strength of the respiratory muscles also decreases, which has been associated with nutritional status and cardiac function. Respiratory flows decrease, characteristically altering the flow-volume curves suggesting small pathway disease.
Aging decreases respiratory reserve during acute disease states. The decrease in the sensitivity of the respiratory centers to hypoxia or hypercapnia alters the ventilatory response in cases of decompensated heart failure, infection or exacerbation of COPD. People are often exposed to the microorganisms that cause this disease, but lung defense mechanisms usually eliminate them. Sometimes, these organisms cheat the immune system and infect the cavities of the lungs. When a patient has pneumonia, the affected alveoli become inflamed and filled with fluid.
8.Why should the RN encourage incidental exercise during Montys admission? How does a patient achieve incidental exercise on an acute ward?
The case shows that Montys has cellulitis on his upper arm from a small scratch sustained while gardening. Incidental exercise constitute one of the best prescription for Montys. Despite the risks involved in a hospitalization for an elderly person, this period is considered an opportunity to change their life trajectory and establish guidelines to prevent the increase of their fragility through a multidisciplinary and multiprofessional intervention (In Theou & In Rockwood, 2015). The study also aims to be a starting point for transferring the benefits of exercising in older people to all healthcare areas (Newson 2013). Incidental exercise, in which strength, balance and gait exercises are performed, is always adapted to the clinical circumstances of each patient and, far from generating complications in their initial health status, is proving to be an important support for the prevention of frailty, a factor of elimination of complications related to the passive stay in the hospital and a way of motivation to overcome the disease (Tinetti, Fried & Boyd 2012). The patient achieves incidental exercise on an acute ward if the organization has an appropriate physical exercise programs tailored to the patient needs. This means that organizational factors as well as the contextual factors determine how a patient achieve incidental exercise on an acute ward.
Physiological Changes Associated with Aging
Likewise, the practice of physical exercise during hospitalization contributes to the reduction of pain and allows breaking with the hospital routine, decreases the risks generated by a passive stay, improves the mood and stimulates the general interest of those admitted and admitted by the patients. benefits of physical exercise.
References:
Barnett, K., Mercer, S. W., Norbury, M., Watt, G., Wyke, S. & Guthrie, B. (2012). Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet, 380 (9836), 37–43
Calderon-Larranaga, A., Vetrano, D. L., Onder, G. et al. (2016). Assessing and measuring chronic multimorbidity in the older population: A proposal for its operationalization. The journals of gerontology. Series A, Biological sciences and medical sciences, doi: 10. 1093/gerona/glw233.
Halvorsen, K. H., Granas, A. G., Engeland, A. & Ruths, S. (2012). Prescribing quality for older people in Norwegian nursing homes and home nursing services using multidose dispensed drugs. Pharmacoepidemiology and Drug Safety 21(9), 929-36.doi: 10.1002/pds.2232.
In Nickel, C., In Bellou, A., & In Conroy, S. (2018). Geriatric emergency medicine. Cham: Springer.
In Pilotto, A., & In Martin, F. C. (2018). Comprehensive geriatric assessment. Cham: Springer.
In Theou, O., & In Rockwood, K. (2015). Frailty in aging: Biological, clinical, and social implications. Basel: Karger.
Kingston, A., Davies, K., Collerton, J. et al. (2014). The contribution of diseases to the male-female disability-survival paradox in the very old: Results from the Newcastle 85+ study. PLoS ONE, 9 (4), e88016.
Maher, R. L., Hanlon, J., Hajjar, E. R. (2014). Clinical consequences of polypharmacy in elderly. Expert Opinion on Drug Safety, 13(1), 57-65. doi: 10.1517/14740338.2013.827660
Mangin, D., Heath, I. & Jamoulle, M. (2012). Beyond diagnosis: rising to the multimorbidity challenge. British Medical Journal, 344 (3), e3526.
Newson, R. B. (2013). Attributable and unattributable risks and fractions and other scenario comparisons. Stata, 13 (5), 672–698.
Payne, R. A., Abel, G. A., Guthrie, B. et al. (2013). The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: A retrospective cohort study. The Canadian Medical Association Journal, 185, E221–E228.
Reuben, D. B. & Tinetti, M. E. (2012). Goal-oriented patient care – an alternative health outcomes paradigm. The New England Journal of Medicine, 366 (9), 777–9.
Smith, S. M., Soubhi, H. & Fortin, M. et al. (2012). Managing patients with multimorbidity: Systematic review of interventions in primary care and community settings. British Medical Journal, 345, e5205.
Tinetti, M. E., Fried, T. R. & Boyd, C. M. (2012). Designing health care for the most common chronic condition – multimorbidity. The Journal of the American Medical Association, 307 (23), 2493–4
Yeoh, T. T., Si, P. & Chew, L. (2013). The impact of medication therapy management in older oncology patients. Support Care Cancer, 21(5), 1287-93. doi: 10.1007/s00520-012-1661-y
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