Introduction
There are various complications that are associated with hospitalization of the elderly person. Hospitalization may not always bring positive outcomes and many times this is the case in the elder population. Hospitalization of an elderly person may have an ‘irreversible decline in functional status and a change in quality and style of life’ (Creditor, 1994, pg219).
Deconditioning is a complex process of physiological change following a period of inactivity, bed rest or sedentary lifestyle. The elderly person suffers ample functional losses in; the mental status, degree of continence and the ability to accomplish the activities of daily living (Brand et al, 2003). This phenomenon can occur gradually or acutely, depending upon the degree of inactivity; and as early as after only two days of bed rest (Hirsch, Sommers, Olsen, Mullen, & Winograd, 1990).
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As part of the multidisciplinary team, nurses are the bridge that links the patient with the rest of the team. This functional role is vital in the frail, elderly patient as the nurse has the ability to slow the process of deconditioning and make the hospital experience less frightening, hence reducing risks associated with hospitalization. The nurse should aim at improving communication and ensuring the patient that the nurse is reachable and accessible and thus the patient comes first and foremost in the line of care.
Complications Associated with Hospitalization of Elderly People.
The majority of complications associated with hospitalization are avoidable; this is because such complications usually arise from other sources which have no relation to the condition the patient presented with on admission to hospital.
Immobility
Immobility means being dependent on others and contributing factors can be; physical or psychological. Part of the aging process means experiencing a decline in activity, leading to weight gain. When these changes are combined with deteriorating vision, balance and coordination the result is a greater risk for falls. (Lazarus, Murphy, Coletta, McQuade, & Culepepper, 1991).
Physical Immobility
The musculoskeletal system is one of the first body systems which show signs of deconditioning. Sarcopenia, diminished muscle mass, muscle shortening, changes in periaticular and cartilaginous joint structure and marked loss of leg strength all seriously limit mobility. Loss of bone tissue and altered bone structure resulting in low bone mass occurs in old age. Decline in muscle mass and strength and bone density means increase in falls, frailty and immobility.
Psychological Immobility
Depression, delirium, dementia and fear are all psychological conditions which occur in old age and contribute to immobility. Elderly people often experience depression as physical symptoms. Anxiety, forgetfulness and confusion are all common features that occur because of depression in the elderly. Fear is a common feeling experienced by old people, especially fear of being alone and of falling.
There are various factors and situations on the ward that contribute to both physical and psychological immobility. For an elderly person who is in the unfamiliar surroundings of the hospital ward and has various attachments such as intravenous and nasal oxygen lines; it would be almost impossible to move, having as much ‘restraints’, let alone using the bathroom or commode (if capable). Due to the new surroundings or other physiological factors, some elderly persons might get disorientated or unsteady on their feet hence are told not to move from bed unless accompanied. This is another factor that contributes to immobility and incontinence as patients might think that calling the nurse for help would mean disrupting her from other important tasks.
Pressure Ulcers
Pressure ulcers are a complication of immobility and occur in physically limited or bedridden elderly. Pressure ulcers may become chronic and remain so for a long period and for some people also a lifetime. A large number of grade 3 and 4 pressure ulcers become chronic wounds, and the stricken patient may even die from sepsis or osteomyelitis due to an ulcer complication. The presence of a pressure ulcer constitutes a geriatric syndrome consisting of multi factorial pathological conditions. The accumulated effects of impairment due to immobility, nutritional deficiency and chronic diseases involving multiple systems predispose the aging skin of the elderly person to increasing vulnerability. (Jaul, E., 2010)
If during the hospitalization period the elderly patient isn’t settled on an appropriate mattress to relieve tension on pressure points, pressure ulcers are sure to occur. If such commodities are not available, turning the patient at least once every two hours should prevent formation of pressure sores.
Urinary Incontinence
With aging comes an increased tendency for urinary incontinence, this is because of a reduced response to antidiuretic hormones in older adults, there is decreased ability to concentrate urine. Bladder capacity reduces with age, and as the kidneys don’t concentrate urine well, frequent urination and nocturia result (Hogstel, M., 2001).
Due to the relaxation of the pelvic muscles, many older women experience incontinence, whilst older men experience frequency of urination because of hyperplasia of the prostate and decreased bladder capacity.
Urinary incontinence is not a normal part of the aging process, but a symptom with an underlying cause. Treatment focuses on finding the underlying pathology through urodynamic testing and a complete history and physical examination.
Sleep
Sleep is one of the activities of daily living and a basic human need. According to Maslow’s hierarchy of needs, sleep has a high priority for survival and is important in many aspects. It helps to restore both; body and brain functions as well as helps in preserving energy, in maintaining general well-being and in preventing illnesses.
Older people report frequent experiences of sleep disruption (Prinz et al, 1990), this may result in consequences such as; multiple physical, emotional and behavioral disturbances. Sleep disturbances among older people are not uncommon even though sleep problems can occur at different ages (Swanson 1999).
During hospitalization, disruption in sleep is very common and this is attributed to environmental influences together with psychological and physical discomfort. When the elderly person is in hospital, feelings of worry and neglect might surface accompanied by the physical discomfort such as pain bestows. Hospital noise such as nurses, patients and equipment don’t really help either (Freedman et al, 1999).
A study conducted in a hospital on elderly people showed that routine nursing practices such as dispensing of medications and monitoring of vital signs played a major role in sleep disturbance during hospitalization. According to Hodgson (1999), disturbed sleep patterns result in; daytime sleepiness, listlessness, lethargy, irritability, confusion and poor-short term memory.
The Role and Actions the Nurse Can Take in Reducing the Risks of Hospitalization
The nurse has a vast role in the hospital setting were the patient is always the centre for concern. The main role of the nurse is to work in preventing progression of condition or disease, restoring health and alleviating suffering. The nurse is also the bridge that links the patient with the rest of the multidisciplinary team and she / he can assume the role of counselor and patient’s advocate when need be.
The nurse can take various measures to reduce the risks of hospitalization in the elderly persons. The nursing process should serve as a guide in goal setting to eventually discharge of the person.
All the following actions reduce the risk of hospitalization;
Communication
Good working relationships and effective communication amongst the nurse and the rest of the multidisciplinary team results in the ideal working environment were all the disciplines involved work together to promote optimum health for the benefit of the elderly person.
Proper daily assessment of the patients’ activities of daily living and adequate delegation of duties should be carried out on the start of every shift.
The chain of communication varies in the hospital setting; starting from nurses between nurses, between nurses and the multidisciplinary team, between the nurse and the patient and between the multidisciplinary team and the family of the patient.
Documentation
Good and effective communication may be also carried out through proper documentation. Apart for legal purposes, documentation is critical to determine if the standard of care was rendered to a patient. Charting should be done properly and reports should ideally be objective, legible, free of errors, accurate and complete. Allergies should be high lightened and no charting should be done in advance. Disconnection and discontinuation of documentation during any time of care can have serious consequences resulting in patient deterioration.
Information
Written leaflets can be given to literate elderly patients and to those who lack this capability, information should be given verbally and in simple language. Relatives can also have access to such information as long as it’s not invasive to the elderly patient.
Handing Over
The handing over should be given out when all the staff (of both shifts) is present and extra care should be taken when verbal orders are given (change of shift reports), noting the doctor’s orders and verifying medication orders.
The Multidisciplinary Team
Satin, 1993 describes the multidisciplinary team as having segregated disciplinary roles, understand other disciplines and their roles, plan together, assign tasks by discipline and their roles, learn and work alone, and avoid intrusion on others’ territories and have competence, role and identity developed within the discipline.
Team building and bonding is necessary for good outcomes in health care. Ideally, at least once a week a meeting where all the members of the multidisciplinary team are invited should be held where the state of health of the elderly patient and planning of further or improvement of care is discussed. During such meetings, the patient can also be referred to other services, such as; appointments and community services.
Members of the multidisciplinary team:
Chaplains
Nurses
Chiropodists and podologists
Occupational therapists
Clinical Psychologist
Pharmacists
Continence advisors
Physiotherapists
Dentists / dental hygienists
Social workers
Dietitians
Speech language pathologist
Doctors, physicians and geriatricians
Family Involvement
Elderly persons tend to be very anxious and scared on admission to hospital therefore, involvement and interaction of the relatives in their care is of vital importance as continuation, knowledge and understanding of care on discharge always brings a positive outcome. The elderly patient and relatives have the right to know what’s going on in the individual’s care plan and procedures should be explained and understood before implementation and queries answered.
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If the elderly person is capable of walking either independently or with a walking aid, the nurse should discuss a care plan with the rest of the multidisciplinary team, such as physiotherapists, occupational therapists, doctors and other members of the team so as to mobilize the individual and promote walking as soon as it is permitted. Walking reduces the risk of incontinence and
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