Category Archives: Aged Care

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Key Elements When Designing and Delivering Effective Indigenous Falls Prevention Programs

05 Sunday Nov 2017

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Falls are now the second most common cause of injury for all Aboriginal and Torres Strait Islander people in Australia

Recovery post fall with serious injury (fractured neck of femur, head injury etc.) does require ongoing care and therapy to optimise functional outcome and quality of life. Rehabilitation and Allied Health services in the Australian general population have been reported to be too inflexible and difficult to access.

Indigenous people report often when trying to access mainstream healthcare of discrimination, judgment and communication problems.

When targeting aboriginal people for health promotion programs there are seven key elements which have been identified by indigenous communities as necessary if it will be accessed and be effective.

Indiginous Specific

A very consistent message is the need for the Health Programs to be indigenous specific. A lot of falls data is general populationrock-art-375225_640which has different demographics to ATSI population. Having the ability to modify the program to incorporate community specific variances that is important for that community.

Community owned

Kinship is a deep sense of family and community and is very strong amongst indigenous population. In communities everyone knows everyone and their family line. Self-determination is also strong in many communities. Preference is for an organisations/groups within the community to deliver any new program. Feeling safe to share their story and how they feel in a friendly environment is important for participants to interact.

No age limit

Along with Kinship is a need for the programs to have no age limit. That way children, carers and partners and family are welcome to attend. Family is not like family as in immediate family. Indigenous family is the community and a concept that whole of the local community is family.

Longer duration

Having a program that is of a longer duration so participants can drop out of and back in is required for any health promotion program. Things come up that prevents attending such as sickness, family reasons, and community responsibilities and the needs of country.

This six weeks or this eight weeks thing, it’s just no good for the Koori [Aboriginal] community because people get sick

 

You can’t offer Koori communities short term fixes because it doesn’t fix anything

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 Group based

Telling a yarn and sharing stories is the foundation of how Aboriginals interact with each other, as a community and the broader Australian community. Kinship is strong. Group based programs rather than one on one programs work best within this framework.

Low to no cost

Again the sharing of resources includes sharing of money. Health is high priority for the government and governmental agencies however for indigenous health is down low in their priorities. Indigenous communities are some of the poorest communities in Australia in terms of money. Preferably no cost programs are required to get people in and engaged.

Transport

Consideration for transport is also an important element which is also related to socio economic reasons. Even if people have a form of transport such as a car it may not be available due to sharing the car with family. Incorporating free transport into the program will remove a probable barrier and encourage greater participation.

Conclusion

Health programs specifically Falls Prevention require modification if wanting to deliver such programs within indigenous communities. Designing the program to be indigenous specific in a group setting factoring in low.no cost and transport is important. Opening the program up to all ages and deliver over a longer period allowing for drop out and in will be more effective with aboriginal communities. Aboriginal communities are best to deliver such programs from already established groups within the community. Underlying all these key elements are the principles of kinship, country and family.

Primary Resource

  1. Lukaszyk C, Coombes J, Turner N J, Hillmann E, Keay L,  Tiedemann A, Sherrington C &  Ivers R (2018)  Yarning about fall prevention: community consultation to discuss falls and appropriate approaches to fall prevention with older Aboriginal and Torres Strait Islander people BMC Public Health 18:77 DOI 10.1186/s12889-017-4628-6

Secondary Resources

  1. Australian Government Department of Health (2013) National Aboriginal And Torres Strait Islander Health Plan 2013-2023 Retrieved from health.gov.au ISBN: 978-1-74241-979-4
  2. Government of Western Australia Department of Health (2010) Falls Prevention for Aboriginal People A tool for Aboriginal Health workers and Aboriginal communities Retrieved from stayonyourfeet.com.au

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Risk of phosphate neuropathy from phosphate based enema use

17 Sunday Apr 2016

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Use of hypertonic sodium phosphate enemas (ie Fleet) in the elderly may cause severe phosphate neuropathy and  hyperphosphatemia.

Deposits of phosphate crystals form within the kidneys causing kidney dysfunction. Sodium phosphate is absorbed into the blood stream due to the significant absorption properties found in the bowel.

Cleansing enemas are used in hospitals for pre operative bowel preparation and when bowel activity has not occurred for many days and the risk of bowel obstruction is real. First line treatment should always be non pharmacological. In addition to strategies below patients should be provided with opportunities to sit on a toilet/commode regularly (at least daily particularly postprandially).

  • patient education                             image
  • hydration
  • diet
  • activity

Enemas distend the bowel stimulating colon contractibility causing stool expulsion. Phosphate enemas additionally stimulate the bowel muscles to contract facilitating stool expulsion. Adverse effects for all enemas irrespective of the active ingredient includes electrolyte imbalance (metabolic derangement) and bowel perforation.

Bowel perforation can generally be related to muscle weakness of the bowel wall, an obstruction or incorrect positioning of the patient during enema administration. Bowel perforation, hyperphosphatemia and phosphate neuropathy may occur, causing death in up to 4% of cases post enema administration.

Symptoms of acute phosphate nephropathy are:

  • lethagy
  • drowsiness
  • decreased urination
  • swelling of ankles, feet and legs.

Symptoms of hyperphosphatemia potentially are:

  • muscle cramps                                               image
  • joint pain
  • tingling and numbness

and in prolonged states:

  • itchy skin
  • pain
  • skin rashes

Patient groups at risk for phosphate neuropathy and hyperphosphatemia are:

  • aged > 65 years

and patients with

  • CKD
  • dehydrated
  • bowel obstruction, delayed bowel emptying or active colitis and
  • on medications (diuretics, angiotensin converting enzyme [ACE] inhibitors, angiotensin, receptor blockers [ARBs], non inflammatories ( NSAIDs) and analgesics (opiates)

Preventing constipation particularly post operatively is vitally important. Being aware of your patients usual bowel habits and routines provides a baseline for the development of their bowel management plan.

“A stitch in times saves nine”

Negating the need to consider the use of enemas is a primary role of the nurse. Asking your patient “have your bowels moved today” is not a rhetorical question. Enquiring about the bowel activities of your patients is only the first step in preventing constipation. Doing something about lack of bowel movements is necessary.

Caution in use of phosphate based enemas for bowel cleansing pre procedure or for treatment of constipation is highly recommended. If administration is prescribed then nurses must be aware of patients at risk for hyperphosphatemia and phosphate neuropathy. Initiating a conversation with the prescriber regards the risks and clinical reasoning for your particular patient is necessary for their safety and wellbeing.

Five questions nurses should ask prior to crushing medication:Legal implications

07 Sunday Feb 2016

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An estimated 55% of drugs are administered unsafely according to 2015 Australian study Downey et al “Don’t rush to crush:audit of modifications to oral medicines for patients with swallowing difficulties”.

In the UK and Australia most drugs are “authorised for marketing” (licenced). The drug must be given (form, dose,ranges) according to its licence. Medical officers and pharmacists have legal authority to prescribe and dispense medication outside the drug license. Nurses do NOT have such authority. 

Altering the form of a drug (ie crushing) for many drugs is operating outside its licence. There are five questions nurses need to ask before proceeding with crushing medication.

1. Is there a valid clinical reason for the need to crush medications?

Patients experiencing difficulty with swallowing medication is common especially in the elderly. A nurse’s role in medication management is to ensure the patient receives their drugs as per the medication regime prescribed by a medical officer.

Crushing medications can destroy the physical and chemical properties of the drug. This can impact on the drugs effectiveness and potentially increase toxicity causing harm to the patient.

Individual preference, family pressure and ‘taking too long to swallow I don’t have enough time to stand here and wait’ are some reasons nurses might crush medications. These are NOT valid clinical reasons to crush.

Difficulty with swallowing (dysphagia) is a valid clinical reason considered appropriate for crushing medication. Nasogastric and PEG tubes being in situ are other valid reasons. If a patient is experiencing dysphagia they should be referred to a speech language pathologist for a swallow review and assessment. 

2. Is the doctor prescribing the medication aware of the nurses intent   to crush the drug?

Nursing concerns regards a patients swallow or requests from patient/family for crushing medication should be escalated appropriately. Assuming the medical officer and pharmacist are aware is not an acceptable response if decision to crush is challenged legally or professionally.

Medication management is a team effort. Patient/family, medical officer, nurse,
pharmacist and speech language pathologist are involved. Assessing and providing treatment for swallowing difficulties is important. A patient with a nasogastric or PEG tube for feeding purposes requires a comprehensive review of their medication regime.

Once a drug is prescribed and supplied outside of its licence (ie crushing in most
instances) the pharmaceutical company is no longer liable for potential side effects or harm. Clinicians making the decision to crush the drug is now liable for potential side effects or harm.

3. Are there alternatives preparations of the drug or alternative drugs available negating the need to crush?

Many drugs are not suitable for crushing ie slow release, enteric coated etc. With
increased technology and manufacturing processes it has become more difficult to determine visually if a drug is suitable to be crushed or not.

In many instances there are alternative preparations of a drug which bypasses the
necessity for crushing. Within each class of drugs are options a prescriber has in treating a condition. This allows the prescriber to choose a drug which has an alternative preparation which may be more suitable.

A conversation between the nurse, prescriber and pharmacist in most instances will be able to problem solve the issues involved without needing to crush the drug concerned.

4. Is the drug suitable to be crushed?

Some drugs are able to be crushed. The prescribing medical officer must be made aware the intent is to administer it by crushing. This needs to be clearly documented by the medical officer preferably on the patient’s medication order.

A valuable resource in Australia is a document “Don’t Rush To Crush”. This was developed in 2011 (and recently revised) by Society of Hospital Pharmacists of Australia. Additionally this text has been added to MIMS Online providing quick and easy access to all clinicians involved in medication management.

“Don’t Rush To Crush” provides comprehensive information of all oral solid drugs
available in Australia including if they can be crushed, the risks associated and how they should be prepared for administration to the patient.

5. Has the patient/family been informed of the risks associated with crushing of medications and provided consent?

Providing treatment and care outside of what is considered “usual care” requires patient consent. Consent includes providing the patient with the rationale/reason for the variance of care, the risks associated and alternative options available. Cushing medications would be considered outside usual care given the legal implications and risk for potential harm. 

The discussion and provision of consent should be well documented in the patients medical notes. The prescribing medical officer is responsible for the gaining of consent. Once a drug is NOT prescribed or administered in the form according to the marketing licence the pharmaceutical company is no longer liable legally for drug reactions.

The prescribing medical officer prescribing a drug outside of the marketing licence is legally liable for drug reactions.

A pharmacist providing a drug in the full knowledge it has been prescribed and/or administered outside of the marketing licence is additionally held liable for any drug reactions.

Nursing staff who crush medications without the knowledge of the medical officer and pharmacist is liable solely for any drug reactions potentially causing patient harm.

Providing safe nursing practice and care to patients is a nurse’s top priority. By asking these five questions of themselves or their colleagues prior to crushing any medication safeguards and protects patients and nurses equally.

Dementia Staging – Focus of Care

13 Sunday Dec 2015

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In 2011 an estimated 298,000 Australians had a dementia and by 2050 this number is expected to triple.

People living with a diagnosis of dementia vary widely in their individual experience of symptoms and the progression of their condition.

Dementia is incorrectly thought of as a disease in its own right. Dementia is in fact a set of symptoms caused by several degenerative disorders.

Various stages and their descriptors have been developed in response to research and a better understanding of dementia. We now know the four most common types of dementia are:

• Alzheimer’s Dementia
• Vascular Dementia
• Dementia with Lewy bodies
• Frontotemporal Dementia (including Pick disease)

Less common is Creutzfeldt-Jakob Dementia and dementias associated with

• Huntington’s disease (HD)                         image
• Parkinson’s disease (PD)
• Alcohol
• HIV/AIDES
• Metabolic causes and
• Trauma

Staging dementia provides a guide for clinicians in determining the focus for treatment. In addition staging also helps in optimising communication among the person with dementia initially, the carers and clinicians.

There are multiple versions of dementia scales which ultimately increases the risk for miscommunication among all parties. The individual dementia scales have been developed focusing on a symptom or group of symptoms and progression through each stage is relative to symptom deterioration.

Alzheimers Australia provides information to health professionals and consumers describing a classical phasing system of Early, Moderate and Advanced Dementia. This scale is based on symptoms associated with cognitive decline although people with dementia do not experience all the symptoms within each of the phases. Cognitive fluctuations make it difficult to articulate clearly at which phase the person is in.

The grouping of symptoms within a four stage framework is described by Dementia Care Australia. This model is based on a social psychology construct rather than a medical one which is based on brain changes.

Progression through the four stages is relative to how the person with dementia is responding and interacting socially within their environment. Research has shown little correlation between brain changes and the symptoms and deterioration experienced by individuals with dementia.

The Clinical Dementia Rating (CDR) scale describes five stages of dementia progression and is based on a persons ability to perform in six areas of function and cognition:orientation, memory, judgement, home and hobbies, personal care and community. Stages are rated as no impairment, questionable, mild, moderate and severe impairment.

A common seven stage scale in assessing primary degenerative dementia is the Global Deterioration Scale (GDS). The GDS focuses on the amount of memory decline and is more relevant and useful in Alzheimer’s Disease (AD). It’s not as useful in some of the other dementias such as frontotemporal dementia as memory loss does not always occur relative to the progression of the dementia.

The descriptive language utilised in the stages and phases of dementia is prolific:early onset, pre-Alzheimers, early, middle, late, mild, moderate, severe,advanced and end stage. Any wonder clinicians find it difficult in clearly communicating with one another and consumers regard the extent of the dementia.

Australian health expert Dr. Jane Tolman describes a dementia scale in her work in this specialised field of healthcare. The model can be used in all types of dementia and has the ability to clearly articulate for clinicians the progression of decline. Focus of care underpins this three stage model.

The first stage is Dignity and Autonomy and the primary focus of care is to maintain independence and enjoyment.

Goal of care in the second stage is about Safety and maintaining quality of life often requiring 24/7 care either in a residential aged care facility or extensive support at home.

Providing Comfort and Dignity is the third and final stage. Symptom management and ongoing reassessment of the need for medications and interventions prolonging life, investigations which do not aide comfort and avoiding hospital presentations is the focus of care.

Just as with other dementia scales progression and the rate of progress through the three stages are variable and individualistic for each person.

Tolmans’ dementia scale is ideal for use in nursing practice and should be considered for use in acute, sub/non-acute and community settings. The focus of care at each stage independence, safety and comfort provide a clear direction for nurses to plan with family/carers ongoing care management for the person with dementia.

Dementia is a progressive and degenerative condition. The focus of care throughout the person/carers dementia journey is to plan for the inevitable palliative aspects of this disorder.

Malnutrition and Hypoalbuminemia – a predictor for illness prognosis

22 Sunday Nov 2015

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40% patients are known to be malnourished on admission to hospitals in Australia. According to Australian Dietetics Association this increases to 70% in residents in Residential Aged Care Facilities (RACF). Malnutrition is clinically suspected in patients with a BMI < 18.5 and unintentional weight loss > 5% body weight.

 

Malnutrition is screened on admission to many Australian hospitals using the Malnutrition Screening Tool (MST) a simple three question tool designed for use by non-dietetic staff.  Patients are referred to Dietetics if they have a score >2 for assessment, review and implementation of a nutrition management plan.  Overweight and obese patients are similarly at risk for malnutrition and benefit from dietetic intervention particularly during times of illness and surgery.

 

General causes contributing to malnutrition are related to

  • inadequate oral intake (NIL by mouth peri-operatively, nausea\vomiting)
  • increased nutritional requirements (wound healing, pressure injuries)
  • impaired absorption
  • altered transport
  • altered nutrient utilisation

 

Malnutrition increases morbidity and mortality. Additionally malnutrition impairs functional recovery, increases muscle loss, impairs wound healing, increases the risk for infection and complications,  increases length of stays (LOS), affects quality of life and increases financial cost for hospitals and organisations. Significant oedema associated with decreased albumin blood levels impacts negatively on mobility and functional recovery. Hypoalbuminemia is also a predictor for morbidity more frequently cardiovascular morbidity, infection and organ dysfunction.

Albumin is a negative acute-phase protein which plays a major role in fighting infections, building and repairing muscle tissue. If the body is not taking in enough dietary protein the liver is less able to make new albumin further decreasing albumin levels. Normal range of albumin in blood is 3.5-5.5 g\l.  Maintaining levels of serum albumin within the normal range prevents the development of tissue oedema through maintenance of the colloid osmotic plasma pressure. The rate of loss of albumin to the tissue spaces (transcapillary escape rate) increases significantly when infection and sepsis if present.

A number of the more complex protocols that have been developed to detect malnutrition in adults rely on changes in acute phase proteins such as serum albumin and prealbumin as primary diagnostic indicators of adult malnutrition.

 

Monitoring albumin levels has been advocated as a prognostic tool to identify higher-risk patients because of the strength of the association and low cost of serum albumin assays. The acute-phase proteins—in particular C-reactive protein (CRP) may help identify the risk of infection or sepsis. Strong correlation between serum albumin and CRP with has been reported.

Studies suggest that administering sufficient exogenous albumin to achieve serum albumin level of more than 3.0 g/L lessens morbidity in hypoalbuminemia patients. Parenteral albumin solutions (200 or 300 mls of 20% albumin) have a good safety record. The ALBIOS study protocol stipulated that albumin administration should be titrated to maintain serum albumin > 3.0 g|l with albumin levels being measured on a daily basis.

Individual factors contributing to malnutrition

  • Age
  • Limited mobility
  • Inability to chew or swallow
  • Sensory loss (taste, smell)                                      th5R8LOT6Q
  • Lack of adequate intake
  • Apathy/depression
  • Treatment (ventilation, surgery, drain tubes)
  • Drug therapy
  • Inability to buy, cook or consume food

Organisational factors contributing to malnutrition

  • Failure to recognise malnutrition
  • Lack of nutritional screening or assessment disease (e.g., cancer, diabetes, cardiac, gastrointestinal)
  • Lack of nutritional training
  • Confusion regarding nutritional responsibility
  • Failure to record height and weight
  • Failure to record patient intake
  • Lack of staff to assist with feeding
  • Importance of nutrition unrecognised

 

Malnutrition and hypoalbuminemia corrective strategies include the screening of all patients on admission to hospitals for malnutrition with a full nutritional assessment for patients identified at risk.  Prescribing of oral supplemental high protein high energy drinks and frequent small meals of choice should form part of a nutritional management plan. Integration of new practises such as protected meal times provides the opportunity for staff to facilitate and monitor oral intake.

Regular blood analysis and review is recommended for patients considered high risk. Studies suggest that for post-operative patients an increased CRP level day 3 post op is a strong predictor for hypoalbuminemia on day 7.

Malnutrition and hypoalbuminemia continues to be unrecognised as such contributing factor in clinical deterioration of patients. Further awareness and education is needed for both nurses and medical staff if prevalence rates are to improve.

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