Management of Common Illnesses, Disease, and Health Conditions Fan, Xiuzhen School of Nursing Shandong University

李某，男，今年 66 岁，与老伴一起生活美满，女儿长大成人，事业有成。然而每 当他想到父亲是 66 岁这一年去世，再联想到自己也到了这个年头，于是不由自主 地感到悲哀。半年来，他总是郁郁寡欢。起初，他感到自己患了绝症，原因是躯 体不适以消化道病最多见，如胃痛、便秘、腹痛、打嗝、食欲减退、失眠多梦。 在多家医院做了详细检查后，他得知自己的胃肠一切正常。但他不相信这些结果， 仍到处求治求医。这时，他对自己正常的躯体功能过度注意，即使有时出现感冒 等轻度疾病，也是反应过度。其次，李老先生情绪特别易激动，发脾气，常为一 些小事与家人争吵不休，弄得家人谁也不敢理他、惹他。他常感到自己年轻时做 过许多错事，不可饶恕（其实，他一直是谨慎严肃的人）。为此他常担心自己和 家庭遭到不幸，不敢走出家门，有时坐卧不安，难以入睡。变得越来越消沉，无 精打采、有孤独感、不想说话、行动迟缓，表情淡漠呆滞。以往很感兴趣的事变 得索然无味，如打牌、抄股、跳舞。他感到自己老了，什么都干不了了。近来， 李老先生越来越悲观，感到自己没用，真是生不如死。他感到父亲在天之灵向他 发出召唤。于是想触电身亡，由于开关跳闸，而自杀未遂。家人为他着急万分， 时时刻刻要人守护他。但李老先生仍企图不断自杀（割脉、服药、上吊 …… ）。 问题： 1. 此病人最可能的诊断是什么？有何依据？ 2. 请列出主要护理诊断／问题。 3. 请列出护理措施要点。

Depression The most common mental health disorder in older adults It ’ s not a normal consequence of aging

Definition American Psychiatric Association defines depression as a disorder that includes changes in feelings or mood Feeling sad, hopeless, pessimistic, or “ blue ” lasting most of the day, with loss of interest in pleasurable activities

Reasons Role changes Major life events Comorbid illness 37%

Medical condition that increase risk of depression Hypothyroidism Heart disease Multiple sclerosis Diabetes Cancer Hypertension Arthritis Huntington ’ s disease Stroke/brain attack Parkinson ’ s disease

Drugs that can precipitate depression Indomethacin ( 消炎痛 ) Diuretics Hydralazine ( 肼苯哒嗪 ) Propanolol Reserpine Levodopa Melatonin ( 褪黑素 ) Digitalis Cimetidine Procainamide ( 普鲁卡因胺 ) Corticosteroids ( 皮质甾类 ) Amantadine ( 金刚烷胺 ) Estrogen

Implications/relevance of depression Suicide Decreased quality of life High health care costs surgical patients: Poorer outcome and lengthier recoveries High mortality rate

Depression, dementia and delirium Delirium Manifestations: Disturbance of consciousness Cognitive or perceptual change Fluctuates during the course of the day Etiology: Sleep pattern disturbances

Dementia Manifestations: 1. Memory loss 2. Disorientation 3. Changes in mood or personality 4. Difficulties in abstract thinking, task performance, and language use

Depression Loss of interest in life and usual activities Fatigue Decreased concentration and short-term memory Changes in appetite Fluctuation in weight and habits Irritability and anxiety

Assessment Geriatric depression scale (GDS) The center for epidemiologic studies depression scale (CES-D) SelfCARE(D) The Cornell Scale for depression (CSDD)

Nursing observations Communication with clients, families and caregivers –to identifying older adults with depression and those at risk of developing depression

Interventions/Strategies for Care Aim: remission and prevention of recurrence –Early recognition of risk and therapy can increase both the quality and quantity of life in depressed older client

Pharmacological therapy Tricyclic antidepressants (TCA) SSRIs---first choice (Selective serotonin reuptake inhibitors) Venlafaxine — SNRI ( 文拉法辛 — 再摄取抑制剂 )

Nursing: to avoid drug-drug interactions Venlafaxine: hypertension, headache, sexual dysfunction, and anxiety SSRIs: sexual dysfunction, nausea, diarrhea, headache, anxiety and tremor TCAs: anticholinergic effects--dry mouth, arrhythmias, and falls Inadequate intake of nutritionExacerbate heart disease Orthostastic hypotension SSRIs, TCAs, serotonin receptor agonists: serotonin syndrome — disorientation, agitation, anxiety, myoclonus, muscle rigidity, hyperreflexia, tremor, ataxia, hyperthermia, diaphoresis, tachycardia, hypertension and tachypnea

Nursing intervention Exercise Light therapy Alternative medicine Counseling Life review therapy: reminiscence

Dysphagia Dysphagia, problem with swallowing It Negatively impacts the quality and potentially quantity of life

Prevalence People experience dysphagia: –7%-10% of people 50 years and older in community –25% of hospitalized patients –30%-40% of people in nursing homes

Implications of dysphagia Risk for nutritional and respiratory problems –Dehydration, malnutrition, eat less, weight loss, hungry after meal –Pneumonia and death No longer found eating to be enjoyable Loss of self-esteem Increasing sense of isolation

Warning signs / risk factors for dysphagia Swallowing process Oropharyngeal Esophageal Neuromuscular impairments--tongue, pharynx, and upper esophageal sphincter Stroke is the leading cause Factors: Cough, regurgitation, dysphonia or dysarthria, inadequate saliva production, thrush Cause: motility problems, neuromuscular problems or obstruction Muscular dystrophy, myasthenia gravis, scleroderma, Achalasia, esophageal spasms, inflammation, Medication irritation Symptoms: food sticking, coughing, Tetracycline, potassium, chloride, quinidine, iron, NSAIDs

Assessment History — 80% of dysphagia – warning signs and symptoms –What type of food causes the symptoms? –Is the swallowing problem intermittent or progressive? –Is heart-burn present?

Physical Examination contents Cognitive Neuromuscular Respiratory Interest in eating Ability to focus on and complete a meal Ability to remember and follow directions for safe eating Sensory and motor components of the cranial nerves, in particular nerves Ⅴ, Ⅶ, Ⅸ, Ⅹ, Ⅺ, Ⅻ Breath sound Strength of the person ’ s cough Ability to clear the throat

Medication review Decrease saliva production: antihistamines, anticholinergics, antihypertensive Decrease cognition: sedatives, hypnotics Decrease the strength of the muscles involves in swallowing: antispasticity drugs

Assessment of warning signs and symptoms Signs of swallowing difficulties or dysphagia Inability to recognize foods Difficulty placing food in the mouth Inability to control food or saliva Coughing before, during, or after a swallow Frequent coughing toward the end of or immediately following a meal Recurrent pneumonia Wet, gurgly voice Weight loss without explanation Complaints of swallowing problems

Assessment of eating a meal Prolonged time “ Picking ” at food Avoid eating Pushing the food away, Turning away from offered food Refusing to open the mouth Environmental factors Distractibility Fatigue Compatibility

Assessment of aspiration while eating Risk assessment after admission

Interventions/ strategies for care Compensatory eating techniques Diet modification Oral care Adaptive equipment

Compensatory eating techniques Upright position: maintained for at least 30-60min after eating Location of food placement in the mouth size, consistency and temperature of food items Safe swallowing Characteristics of the environment: quiet, assistance, posture, Unhurried calm demeanor, limit conversation, but response needed to provide information about changes in voice quality, and pleasant social experience

Diet modifications The National Dysphagia Diet (NDD) ： Guideline for treatment of dysphagia. Examples: Dysphagia Pureed (NDD1): “pudding-like” consistencies; pureed, no chunks or small pieces; avoid scrambled eggs, cereals with lumps Dysphagia Mechanically Altered (NDD2): moist, soft-foods; easily formed into a bolus; ground meats; soft, tender vegetables; soft fruit; slightly moistened dry cereal with little texture. No bread or foods such as peas and corn. Avoid skins and seeds. Mechanical soft: same as the mechanically altered, but allows bread, cakes, and rice. Dysphagia Advanced (NDD3): Regular textured foods except those that are very hard, sticky, or crunchy. Avoid hard fruit and vegetables, corn, skins, nuts, and seeds. Liquid Consistencies: Spoon thick, Honey-like, Nectar-like, Thin: All beverages such as water, ice, milk, milkshakes, juices, coffee, tea, sodas

Oral hygiene Regular cleaning of the teeth or dentures, gum, and tongue ， and maintaining moisture in the mouth Maintaining moist mucous membranes

Adaptive equipment Non-oral feedings Managing gastroesophageal reflux

张某，男， 72 岁，既往从未有过脑卒中发作。近 2 年来逐渐出现 记忆力减退，起初表现为新近发生的事容易遗忘，如经常失落物 品，经常找不到刚用过的东西，看书读报后不能回忆其中的内容 等。症状持续加重，近半年来表现为出门不知归家，忘记自己亲 属的名字，把自己的媳妇当作自己的女儿。言语功能障碍明显， 讲话无序，不能叫出家中某些常用物品的名字。个人生活不能料 理，有情绪不稳和吵闹行为。体格检查未发现神经系统定位征， CT 检测提示轻度脑萎缩。 问题： 1. 此病人最可能的诊断是什么？有何依据？ 2. 请列出主要护理诊断 / 问题。 3. 请列出护理措施要点。

Dementia AD Other vascular dementia dementia with Lewy bodies Parkinson ’ s dementia The most common type of dementia in the older adults Alzheimer ’ s Disease (AD)

Risk factor for AD Advances age is the single most significant risk factor 70% people with AD live at home until the latest stages AD has a great impact on our society

Characteristics Progressive memory loss Eventually leaving a person completely dependent upon others for care

Pathology A growth of β-amyloid plaques and neurofibrillary tangles That interfere with normal cell growth and the ability of the brain to function Absolutely definitive diagnosis is still through autopsy

Stages of AD Alzheimer ’ s Association Seven stages With no symptoms to mild symptoms and diagnosis occurring in the first three phases Early, middle and late phases depending on source consulted

Clinical demonstrations Early phase A loss of short-term memory It involves more than common memory loss such as where the keys were put, It may involves safety concerns such as forgetting where one is going while driving The inability to perform math calculations and to think abstractly may also be evident

Middle or moderate phase Many bodily systems begin to decline Confused as to date, time, and place Impaired Communication skills Personality changes As cognitive decline worsens, the person may forget the names of loved ones, even their spouse Wandering behavior Emotional changes, screaming, delusions, hallucinations suspiciousness and depression Unable to care for personal hygiene

Most severe and final phase A severe decline in physical and functional health Loses communication skills Unable to control voluntary function Death results from body systems shutting down

Diagnosis Early diagnosis is important to maximize function and quality of life for as long as possible Warning signs of AD Memory loss Difficulty performing familiar tasks Problems with language Disorientation to time and place Poor or decreased judgment Problems with abstract thinking Misplacing things Changes in mood or behavior Changes in personality Loss of initiative

Treatment Medication: to help symptoms such as memory, not slow the disease course –Aricept ( 安理申，盐酸多奈哌齐 ) –Namenda ( 盐酸美金刚 ) –Razadyne ( 加兰他敏 )

Nursing care Symptom management: behavior, safety, nutrition and hygiene –A safe and controlled environment –Modified surroundings to accommodate wandering behaviors –Nursing care 24 hours a day Medication management Outcomes of therapies record

Care for the caregivers — educating –Time management, maximizing resources, and managing changing behavior –Emotional adjustment

Thank you!