Falls and Palliative Care - Exam 2 Flashcards
________ have a significant impact on the patient’s quality of life and are associated with ?????
vision impairment
social isolation, anxiety, depression and a loss of independenceq
What is considered normal vision? visual impairment? legal blindness?
What is considered extraocular motion?
difficulty in gazing upward and maintaining convergence
**What is hyperopia?
Hyperopia (farsightedness) is an eye condition that causes blurry vision when looking at things close up (like words in a book)
can see far away but NOT up close
**What is myopia?
Myopia is the medical name for nearsightedness, which means that you can see objects that are near clearly but have difficulty seeing objects that are farther away.
What is the MC cause of blindness? name 3 more
cataracts
diabetic retinopathy
open-angle glaucoma
late-age related macular degeneration
What tests should be included as part of the vision impairment testing?
What does monocular defect represent?
disorder of the retina or optic nerve
What does a binocular defect represent?
disorder of chiasm, cortex or bilateral eye disease
What does asymmetric pupil response make you think?
optic nerve or autonomic nervous system disorder
What does darkened red reflex on ophthalmoscope make you think? large cupping?
possible cataract
possible glaucoma
What does disc pallor on ophthalmoscope make you think? hemorrhages? white spots?
disc pallor= optic atrophy or end-stage glaucoma
hemorrhages= possible diabetic or hypertensive retinopathy
white spots= macular degeneration or exudate due to DM or HTN
If a pt complains of rapid onset, marked loss of central vision in one eye, what should you do?
ASAP referral to ophthamology
**If a pt complains of rapid onset, marked loss of central vision in one eye, what should you do?
ASAP
**If a pt presents with bilateral slow onset, mild loss with decreased central vision, what should you do?
less urgent (4-6 week) consult with ophthalmology
**If a pt present with monocular moderate-to-severe photophobia with ocular pain, what should you do?
ASAP referral to ophth
**What would you do if a pt presents with monocular loss of peripheral vision?
ASAP or urgent referral
**What would you do if a pt presents with binocular loss of peripheral vision?
urgent referral to ophthmalogy
**What is hearing loss exacerbated by?
Previous middle-ear disease, vascular disease, and noise exposure
What are the 3 age related changes of the inner ear?
Atrophy, disappearance of cells, and angiosclerosis
Calcification of membranes
Bioelectric and biomechanical imbalances
What are the age-related changes of the 8th cranial nerve?
Degeneration and loss of ganglion cells and their fibers
Nerve canal closure with destruction of nerve fibers
What are the 4 age related changes of hearing impairment?
inner ear
changes in the 8th cranial nerve
Atrophy and cell loss at all auditory centers in the brainstem
Reduction of cells in auditory areas of the cortex
______ is a required element of the initial Medicare annual wellness visit. What tests should you do?
Hearing loss screening
weber/rinne
whisper test
____ is common in older adults and can lead to significant hearing loss. Hearing loss in older adults is usually of the ______. What is another name for it?
Cerumen accumulatio
sensorineural type
presbycusis
**What do the results of the Rinne and Weber test indicate?
What are the tx options for hearing impairment?
functional strategies
hearing aids
aural rehab
_____ are a major cause of morbidity in the geriatric population. _____ can negatively impact functional status and overall quality of life. What can happen as a result?
Falls
Fear of falling
Repeated falls and consequent injuries can be important factors in the decision to institutionalize an older person
What are the causes of falls in the geriatric population?
medical, neuro or psych condition
impaired vision or hearing
age related changes in muscular function, postural reflexes and gait
medications
unsafe footwear
poorly fitted or improperly used assistive devices
environmental hazards
What are some common environmental hazards that can lead to falls?
What should you do when doing the historical evaluation regarding falls on a pt?
general medical history
hx of previous falls
medications: (esp antihypertensives and psychotropic agents)
pt’s thoughts on the cause of the fall
circumstances surrounding the fall
associated symptoms
LOC
What is considered orthostasis?
drop in 20 systolic or 10 diastolic pressure when changing positions from lying, sitting, standing etc etc
What should be included as part of the PE when working a pt up for falls?
vital: orthostasis
skin
eyes
cardiovascular
extremities
neurological
What are the 2 functional assessments tests you can do in office with a geriatric pt?
“Get up and go test”
Functional reach test
What are the pt education instructions for the “Get up and go test”? What should you as the evaluator be looking for?
Patient is instructed to stand from a seated position (without using armrests if possible), walk forward about 10 feet, turn around, walk back to chair and be seated (time patient from initial rise to re-sitting)
Evaluator should be examining patient’s sitting balance, transfer from sitting to standing, pace, and ability to turn around without staggering
What are the pt education instructions for the functional reach test? What indicates an INCREASED risk of falling?
Patient stands with fist extended alongside a wall
Patient leans forward as far as possible, moving fist without taking a step or losing stability
Length of fist movement is measured
Distances of LESS than 6 in (15 cm) indicate an INCREASED risk of falling
What is the interpretation of the “Get up and go test?”
_____ of falls in the geriatric population lead to serious injury. Falling is a major cause of _____
10-20%
hip fractures
What are the top 3 serious injuries related to falling?
Major lacerations / soft tissue trauma
Head trauma
Fractures
Patients who suffer from fall-related injuries are more likely to experience a ____ in functional status and ____ in medical service use
decline
increase
Define immobility
Defined as the state in which an individual has a limitation in independent, purposeful physical movement of the body or of one or more lower extremities
immobility is a major concern in the development of ______
decubitus ulcers
decubitus ulcers are Skin breakdown over bony prominences, most commonly the ______, _______, and _______.
sacrum, heels and trochanteric areas
What are the decubitus ulcers risk factors? Which ones are modifiable?
**What are the different stages of a decubitus ulcer using characteristics?
What is an unstageable pressure injury?
slough or eschar obscures the extent of tissue loss
What are the different stages of a pressure ulcer using layers of skin?
_____ is the best management strategy for decubitus ulcers
Prevention
What is the tx for stage I and II ulcers?
aka turning and padding
prevent infection and from getting worse
**What is the tx for stage III ulcers?
**What is the tx for stage IV ulcers?
_______ a person’s right to make their own decisions
autonomy
______ doing no harm and avoiding
negligence that leads to harm
nonmaleficence
_____ the duty to promote what is best for others and avoid harm in the process
beneficence
______ Promotes nondiscrimination and the duty to treat individuals fairly
justice
What are the guidelines that forbid clinicians from providing care that….. what 3 things?
Does more harm than good
Is ineffective
Stems from malicious or selfish acts
______ consistently treating all patients equally requires awareness of _____ and _____ in the healthcare system
justice
implicit bias
discrimination
_______ the ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment or intervention. Who is it determined by?
capacity
determined by any practitioner
_______ A person’s ability to act reasonably after understanding the nature of the situation being faced. Who is it determined by?
competence
determined by a court of law
______ can help in determining cognitive dysfunction that might interfere with decision-making. What is the most reliable?
cognitive assessment
clock draw is the MOST reliable
What are the 5 guidelines to follow when determining decision making capacity?
What are the principles of informed consent?
The patient has the right to choose among medically feasible options and the right to refuse unwanted interventions and treatments
What is included in the informed decision-making process?
Nature of the proposed intervention
Potential benefits, risks, and longer-term consequences of intervention
Alternative interventions or treatments
Option of not going forth with a treatment along with risks and long-term consequences
_________ is the federal law that requires that all persons entering a hospital or long-term care facility be offered the opportunity to indicate ADs
Patient Self-Determination Act (1990)
If medical power of attorney has NOT been appointed, what is the legal default order?
Spouse → then adult children → siblings → parents → health care team
What is palliative care?
Medical care focused on improving quality of life for people living with serious illness regardless of prognosis
What is considered a serious illness?
a condition that carries a high risk of mortality, negatively impacts quality of life and daily function, and/or is burdensome in symptoms, treatments or caregiver stress
____ fits under the broader term of palliative care. What is a distinct feature of this type of care?
hospice
Patients must forgo curative treatments for their terminal disease
What is hospice care? **Who pays for hospice?
A form of palliative care when there is a limited life expectancy (less than 6 months to live)
Part A Medicare coverage
Who determines what pts qualify for hospice?
Two clinicians have determined the patient has* ≤ 6 months to live* if disease runs its expected course
**What are the 2 big services provided by hospice?
nursing and social services
What is the goal of PM in palliative care?
treat pain proactively and find the minimal dose of medication that can prevent pain
What is first line for mild pain in palliative care? **What is used for moderate/severe pain?
Acetaminophen (Tylenol)
**opioids
____ can exacerbate dyspnea in patients in the palliative care setting. Evidence supports that ____ relieve the sensation of breathlessness
lengthy conversations- need to be avoided
opiates
Patients may have secretions that they can not expectorate which can be uncomfortable and exacerbate dyspnea so _____ may be helpful. Specifically _____ or _____
anticholingergics: to help dry up secretions
hyoscyamine or atropine
______ is used for gut inflammation and chemotherapy N/V. What drug class?
ondansetron (Zofran)
serotonin receptor antagonist
______ is used for motion-induced/labyrinthitis. What drug class?
Scopolamine patch-> anticholinergic
promethazine (Phenergan) -> 1st gen antihistamine
______ is used for increased intracranial pressure N/V
Dexamethasone (Decadron)
How do you differentiate depression from grief?
Feelings of hopelessness, helplessness, worthlessness, guilt, lack of pleasure, and suicidal ideation are key in distinguishing depression from grief
______ are often effective in decreasing agitation at the end of life
Small doses of antipsychotics (eg, haloperidol 0.5 mg)
Hospice should be consider in any advance dementia case complicated by ________, _____ or ______. What do they suggest?
pneumonia, febrile episode, or eating problems
markers of poor 6-month prognosis
in palliative care do not delay the treatment of what 4 things?
pain
nausea
secretions
cough
you should NOT offer _____ in palliative care
PEG tubes
DO NOT OFFER PEG TUBES
Always consider _____ and ____ in palliative care
palliative sedation and involving clergy/spiritual leaders
