Study Guide Q's: Medically Complex Older Adults Flashcards
1
Q
what are caregiver stressors? (4 areas)
A
-
Physical health
- Physical strain
- Injuries from lifting
- Transferring
- Repetitive actions
- Caregivers may neglect their own health
-
Psychological health/QOL
- Emotional distress (depression, anxiety)
- Nearly 50% report emotional difficulty
-
Social well being
- Reduced access to social network
- Decreased conflict resolution
- Reduced time for leisure and social pursuits increases emotional stress
- Potential for family conflicts
-
Economic well being
- Direct cost of caregiving
- Taking on debt
- Financial strain
- Nearly 40% of caregivers report moderate to high degree of financial strain
2
Q
PT considerations for caregiver stressors
A
- Physical health: assess home environment and abilities and safety of caregiver
- Psychological health/QOL: use caregiver burden scales or open conversation about stress levels
- Social well-being: use caregiver burden scales or open conversation about stress levels
- Economic well-being: access community resources
- Overall: provide resources to help caregivers cope with stress, identify community resources
- CARE Act (Caregiver Advise, Record, Enable)
- Caregiver intervention programs
- Professional support
- Psychoeducational
- Behavior management/skills training
- Counseling/psychotherapy
- Self-care/relaxation techniques
- Environmental redesign
- Programs can also extend to help bereavement adjustment
3
Q
caregiver burnout
what does it increase risk for?
A
- Definition: state of physical, emotional, and mental exhaustion and distress that may include depression, agony, anxiety, etc.
- Burnout syndrome: emotional exhaustion, depersonalization, reduction in personal fulfillment
- Effects
- Interferes with quality of care
- Risk of mental/physical problems for the caregiver
- Early patient institutionalization
- Increased risk for abuse
4
Q
complete an efficient chart review
A
- Chart review:
- Summary of why the patient came to the ED
- PMH
- Past surgical history
- Medications
- Lab values
- Diagnostics (xray, MRI, CT, ECG)
- Other provider notes (OT, SLP, MD, OR reports, etc.0
- Note: You may also see complex patients in outpatient settings
5
Q
coronary heart disease effects (8)
A
- elevated LDL’s
- Elevated total cholesterol
- Systolic hypertension (if untreated LV hypertrophy)
- Increased arterial stiffness and ventricular wall thickening
- Endothelial dysfunction –> vascular constriction
- Changes –> reduced EF increased O2 demand –> ischemia
- Physical inactivity + excessive caloric intake + decreased muscle mass + decreased metabolic –> obesity
- physical inactivity –> activity intolerance –> functional limitations
6
Q
coronary heart disease comorbidities (5)
A
- obesity
- DM
- Cancer (CA)
- Atherosclerosis
- Mortality and decreased life expectancy
7
Q
coronary heart disease standards of diagnosis
- what is the gold standard diagnosis?*
- what range do you want cardiac enzymes in?*
- troponin, CK, BNP*
- What are the most common meds? (5)*
A
- gold standard diagnostics
- graded exercise testing
- cardiac cath
- cardiac enzymes
- troponin: <0.1-0.3 ng/mL
- CK 0-3 ng/mL
- BNP <100 ng/mL
- Common meds
- diuertics
- beta blockers
- CCB
- ACEi, ARBs
- Statins
8
Q
acute coronary syndrome definition
- What leads to ACS?*
- What 3 things does it include?*
A
CAD -> ischemia -> ACS
Definition: severe imbalance of O2 demand and supply
Includes: unstable angina, NSTEMI, STEMI
9
Q
Acute coronary syndrome comorbidites (3)
A
concomitant increased risk for
- respiratory failure
- syncope
- stroke
10
Q
Heart failure effects
- what is the leading cause? Second leading cause?*
- List 4 general symptoms.*
A
- pump dysfunction –> metabolic needs unmet
- leading cause: ischemic LV dysfunction due to CAD
- Second leading cause: HTN
S&S:
- fatigue
- SOB
- decreased activity tolerance
- mixed L and R S&S
11
Q
A
12
Q
Heart failure comorbidites (3)
A
associated with structural defects:
- valvular disease
- CAD
- HCM
13
Q
Heart failure standards of diagnosis
- what 8 things should you assess for?*
- what are 4 common meds?*
A
asesses for:
- pitting edema
- JVD
- Adventitious breath sounds
- Dyspnea
- Orthopnea
- Tachypnea
- Desaturation
- BNP values
Common Meds:
- Diuertics
- ARNI’s
- Anti-HTN
- Digoxin
14
Q
pitting edema scales
A
0: normal
1: barely perceptible
2: rebounds in <15 seconds
3: rebounds in 15-30 seconds
4: rebounds > 30 seconds
15
Q
pulse pressure
what is normal and what requires medical attention?
A
- systolic – diastolic BP
- Normally 40mmHg
- >60mmhg requires medical attention
16
Q
Orthostatic hypotension
A
20mmhg in SBP, or 10mmHg drop with increased HR
17
Q
response to exertion (HR, BP)
A
- Normally HR increases 10-20 BPM per MET level
- Normally BP increases 10-12mmHg
18
Q
recovery from exerrtion HR response
what does reflexive HR after exercise indicate?
A
- Within the first minute, there should be a significant decrease in BP and HR
- Reflexive HR increase suggests venous pooling or orthostasis
19
Q
diagnosis of pneumonia (5)
A
- Chest x-ray
- Positive findings or infiltrates or consolidation
- Elevated WBC count
- Desaturation of SaO2 even at rest
- Chest pain, pleuritis
20
Q
common meds for pnuemonia (3)
A
- Antibiotics
- Antivirals
- Oxygen
21
Q
regular nasal cannula LPM and FiO2
A
LPM: 1-6
FiO2: 24-44%
22
Q
High flow nasal cannula LPM and FiO2
A
LPM: up to 60
FiO2: Up to 100%
23
Q
Partial rebreather mask LPM and FiO2
A
LPM: 6-10
FiO2: 60-80%
24
Q
A
25
Q
Non rebreather mask LPM and FiO2
A
LPM: 10-15
FiO2: 60-80%
26
Q
Salter high flow nasal cannula
A
LPM: Up to 15
FiO2: 54-75%
27
Q
pulmonary PT considerations
- what is the average respiratory rate (breaths/min)
- What is the inspiratory/expiratory ratio
- what ratio suggests hyperventilation/decreased PaO2 and what 2 conditions might cause this?
- What ratio suggests hypoventilation/increased PaO2 and what condition might cuase this?
- How many syllables per breath at rest?
- What is the error rate for a pulse ox? What is the best place to use it?
A
- Observations for the PT
- Respiratory rate
- Average is 12-20/min
- Inspiratory: expiratory ratio
- Normally 1:2
- 1:1 suggests hyperventilation and decreased PaO2 (anxiety, uncontrolled DM)
- 1:3 suggests hypoventilation, increased PaCO2 (hypoxia)
- Observe expansion of chest walls in all directions
- Speech
- Should have 12-15 syllables per breath at rest
- Pulse ox
- Up to 5-6% error rate
- Accuracy decreases in dark pigmented patients
- Earlobe is the most accurate placement
- Auscultation
- Normal vs. adventitious sounds
- Respiratory rate
28
Q
UTI PT considerations
- what percent of nursing home infections does this account for?*
- What is the primary cause in older women? Older men?*
- How does a UTI present symptom wise in older adults?*
A
- Accounts for 1/3 of infections in nursing home residents
- Causes
- Primary cause: urinary stasis
- Older women
- Decreased pelvic floor strength
- Decreased estrogen levels
- Older men
- Decreased bladder emptying due to BPH
- Older women
- Indwelling catheter
- Primary cause: urinary stasis
How does this often present in an older adult?
- S&S not always the same as in younger patients
- Big change in older adults is acute delirium
29
Q
Sepsis definition
what is it is the leading cause of?
A
- Definition: life threatening organ dysfunction caused by a deregulated host response to infection
- Leading cause of hospitalization and most expensive inpatient condition
30
Q
Pathophys of sepsis
A
- Differentiated from infection by a dysregulated host response that results in organ dysfunction
- Loss of adaptive homeostasis in response to infection
- High degree or mortality risk with organ dysfunction
- Urgency for early recognition of sepsis and prompt restraint
- Anti-inflammatory response fails to develop
- Proinflammatory process becomes unregulated
- Results in a cascade of dysfunction
- Increased microvascular permeability with transduction into the organs
- Platelet sludging –> capillary blockage, ischemia
- Reperfusion injury
- Dysregulation of vasodilatory and vasoconstrictive mechanisms
- Maldistribution of blood flow –> shock
- Immunosuppression from excessive anti-inflammatory response
Organ failure –> multiple organ dysfunction syndrome
31
Q
S&S of Sepsis
- lactate level?
- HR?
- RR?
- 3 other things?
A
- Lactate >18mg/dL
- Hypotension
- Fever >103 degrees
- HR >90 BPM
- RR >20 breaths/min
- Often confirmed infection from culture
32
Q
clinical manifestations of sepsis
- CV (5)
- Pulmonary (4)
- CNS (3)
- Renal (2)
- GI (2)
- Hepatic (3)
- Hematologic (4)
A
-
Cardiovascular
- Hypotension
- Tachycardia
- Elevated CO (drops with septic shock)
- Systemic vascular resistance drops with septic shock
- Hypoperfusion exacerbated -> lactate accumulation
-
Pulmonary
- Tachypnea
- Hypoxemia (VQ mismatch)
- Respiratory alkalosis
- Pulmonary edema and respiratory failure -> ARDS
-
CNS
- Altered mental status
- Encephalopathy
- Polyneuropathy
-
Renal
- Oliguria (abnormal low urine production)
- Azotemia (elevation in BUN & serum creatinine)
-
GI
- Impaired motility
- Stress ulceration
-
Hepatic
- Elevated serum transaminase
- Hyperbilirubinemia
- Final stages: hepatic insufficiency
-
Hematologic
- Leukocytosis
- Multifactorial edema
- Thrombocytopenia and coagulation abnormalities
- Disseminated intravascular coagulation (DIC) is a late stage manifestation that carries poor prognosis
33
Q
progression of sepsis to septic shock
A
sepsis –> severe sepsis –> septic shock
34
Q
septic shock criteria definition and mortality
- what type of hypotension?*
- What blood lactate volume?*
A
- Definition: abnormal circulatory and cellular metabolism profound enough to significantly increase mortality
- Criteria
- Persisting hypotension that requires vasopressors to maintain MAP at 65mmHg or greater
- Blood lactate >2mmol/L despite volume resuscitation
- Mortality is 4x greater than when these criteria are met
41
Q
Examination vs. Clinical Signs and Symptoms for Dehydration
A
47
Q
How is metabolic syndrome diagnosed?
A
69
Q
be able to apply this diagram to a clinical scenario
A
71
Q
etiology of fraility
A
- Multifactorial
- Genetic
- Environmental
- Metabolic
- Lifestyle stressors
- Acute and chronic diseases
- Result in multisystem impairments across multiple physiologic systems
- Impaired homeostatic mechanisms
72
Q
how does fraility look across the ICF model?
A
73
Q
treatment parameters for a pre-fail adult vs. frail adult picture
A
80
Q
primary prevention of fraility in the context of the triple Aim
A
- Regular engagement in moderate to vigorous physical activity
- Cognitively stimulating activities
- Healthy diet and supplementation as needed
- Ideal sleep
- Maintaining proper body weight
- Metabolic control (blood sugar, blood pressure, blood lipids)
81
Q
secondary prevention of fraility with the Triple Aim view in mind
A
- Use assessment tool to identify key underlying deficits
- Implement a multimodal approach
- Medication management
- Falls prevention
- Nutritional support
- Social/psychological support
- Exercise program
83
Q
what is the difference between osteoporosis and osteopenia?
A
- Osteopenia: low bone density that compromises the bone’s ability to absorb loads (lower than normal, but not as low as osteoporosis)
84
Q
what are T scores?
A
- T scores
- WHO diagnostic classification in postmenopausal women or men over 50
- Cannot be applied to young population
- From Google: Your T-score compares your bone mass to that of a healthy young adult. The “T” in T-score represents the number of standard deviations, or units of measurement, your score is above or below the average bone density for a young, healthy adult of your same sex.
