CNS ROLE APPLICATION
Dec 24, 2015
ELDER LIFE CNS ROLE –SPHERES OF CARE INFLUENCE
Patient level – comprehensive geriatric assessment, protocol driven, follow up assessment and interventions, education for patients and families
Staff level – coaching and education on delirium prevention and functional decline; participation in care rounds
System level – program operation, quality assurance, identification of care gaps and interventions
HELP NURSING PROTOCOLS
Targeted Risk Factor Approach using protocols
Evaluation of Cognitive Status• Delirium Protocol • Dementia Protocol • Psychoactive Medications Protocol
Sleep Enhancement Protocol Early Mobilization Protocol
MORE HELP NURSING PROTOCOLS Hearing Protocol
Fluid Repletion Protocol
Discharge Planning Protocol
Optimizing Length of Stay Protocol
Additional Areas –
EXAMPLE: DELIRIUM PROTOCOL
Assessment establishes baseline, cognitive tool plus
CAM and collateral history psychoactive medications and ETOH use bloodwork then daily- structured cognitive tool plus the
CAM and ongoing staff, family and volunteer inputs
IF PATIENT CHANGES SUDDENLY ….
Review medication list for potentially contributory medications or potentially harmful interactions
Search for occult infection, e.g., urinary tract infection (UTI)
Rule out drug or alcohol withdrawal Support referrals to geriatrics, pharmacy,
internal medicine
MORE DELIRIUM INTERVENTIONS
Non-Pharmacological Management
Education for staff, involve family
Strategies to decrease agitation and improve sleep
Communication techniques
AT HHS, THE HELP NURSE ……. Follows HELP delirium protocols
Structured cognitive assessment is not carried out daily but on admission and as indicated
No discharge sMMSE is completed
ADHERENCE-WHAT DOSE OF HELP IS ENOUGH ?
The Role of Adherence on the Effectiveness of Nonpharmacologic Interventions
Higher levels of adherence resulted in
reduced rates of delirium in a directly graded fashion, with extremely low levels of delirium in the highest adherence group.
Inouye SK. Arch Intern Med. 2003;163:958-964
AT HHS…… 2005 ADHERENCE
68%-best for orientation, vision and hearing , therapeutic activities and feeding protocol
34% -lowest for mobility and sleep protocol
COGNITIVE SCREENING INSTRUMENTS
Instrument Admin time Comments
Sweet 16 3-5 mins Published Nov 2010- on HELP website
Mini-Cog 3-5 min Brief , validated
Short portable status questionnaire
3-5 minutes Brief
3MS 10-15 mins MMSE plus remote memory, verbal fluency and abstraction
sMMSE/Folstein 10-15 Copyright requires authors permission- per use fee with Folstein
Montreal Cognitive Assessment (MoCA)
10-20 minutes Open access-
THE SWEET 16
PURPOSE: screening tool for cognitive impairment
Why another tool? Length, burden ,copyright ADVANTAGES : simple, rapid, paperless, validated against the MMSE, open accessCONSTRAINTS : early days of testing
Fong,T. Arch Intern Med. 2010 Nov 8
HISTORY OF PRESENTING ILLNESS
Sudden increase in low back pain 3 days ago; unable to walk, new onset of urinary incontinence. GP started Lorazepam 1 mg Q HS 5 days ago for poor sleep. Confusion over 48 hours –disoriented to time, not consistently recognizing family
PAST MEDICAL HISTORY
Hypothyroidism Dyslipidemia Hearing loss Macular degeneration Hypertension ?TIA Arthritis Chronic Low Back Pain Degenerative Disc Disease, Scoliosis
SOCIAL HISTORY
Widowed, 3 children, 9 grandchildren Retired teacher – grade school and ESL Enjoys listening to music, attending
socials and visiting with families
BASELINE FUNCTION
Walks with walker independently to D/R
Toilets independently; no history of incontinence
Assisted with bath 2 X per week 1 year history of short term memory
loss, repeats stories, forgets family visits
INVESTIGATIONS
CT scan: no obvious fracture except for possibly a displaced right transverse process fracture of L3
LabsLab Findings Normal Range
urea 11.2
Creat 115
TSH 18
WBC 13,3
Hgb 130