peers discussion response

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Hi, i just need a discussion response to this two discussion 1 and discussion 2 posts. please try and do intext reference for both. You do not have to reference from their own references. You can add to what they have written or elaborate more on what they have written. Please write in an upper level grammer. I am not sure if you are the one writing this. Your earlier works are better than what you are doing recently. If someone is helping you, please find someone else. I really want to continue with you, please dont chase me out. I do not have any opportunity to fail a class and so will not take the risk, please.

Discussion 1

For this assignment, you will review the case study below and post a discussion for the class answering the noted questions.

You are evaluating a 78 year old white male who comes to your office today with unintentional weight loss of 10lb in the last year, self-reported exhaustion weakness based on grip strength, and slow walking speed, and low physical activity. Notes that he has been feeling worse over the past 6 months and just does not have the strength to do anything anymore. The patient states they are not currently on any medications except a multivitamin. He notes that he lives alone and does not want to leave his house. Answer the following questions with supportive rationale:

  1. What questions should you ask the patient/family to further assess?

According to Goolsby & Grubbs (2015),

It is important that nurse practitioners have a basic understanding of the risk factors, causes, and clinical presentations of geriatric syndromes and routinely assess for factors that may be amenable to intervention beyond the medical issues. Prevention is particularly important in managing geriatric syndromes both in the hospitalized and in the community-residing elder (p. 613).

Questions that should be asked for this case to further assess the patient include: Tell me about your functional status, what does your typical day consist of? Have you had any falls? Are you able to complete your routine activities of daily living? Tell me about your adequacy of sleep, do you take naps? Do you feel happy most of the time? Have you noticed any cognitive changes or impairments? Have you noticed any change in appetite? Can you tell me what you ate over the last 24 hours? Do you wear dentures; if so do they fit you well or are they lose? Do you experience any tremors or dizziness? Do you feel unbalanced when you stand? Any urinary or bowel incontinence? Have you noticed any skin breakdown? Any shortness of breath or chest pain? Do you still drive; if so, do you ever feel uncomfortable while driving? Do you drink alcohol? Has the patient been forgetful (Goolsby & Grubbs, 2015)? Goolsby & Grubbs (2015) report,

The assessment of older individuals requires a thorough understanding of physiology, awareness of the client’s environment, good communication skills, avoidance of ageist thinking, and good critical thinking ability—plus time and patience. It is often the lack of time that leads to problems. Sufficient time to perform some of the additional tests of functional ability and to talk with family and caregivers is optimal (p. 625).

  1. What screening tools would be appropriate in this case?

Screening tools that would be appropriate in this case include: the Comprehensive Geriatric Assessment (CGA), the abbreviated CGA (aCGA), the Vulnerable Elders Survey-13 (VES-13), the Groningen Fraility Indicator (GFI), and the Geriatric 8 (G8) (Smets et al., 2014). Formal assessments that may also be used include: PRISMA-7 Questionnaire, Gait Speed Test, Timed Up and Go Test (TUG), Standardized Mini Mental State Exam (SMMSE), and the Montreal Cognitive Assessment (MoCA) (British Columbia Guidelines, 2017).

  1. Do you have concerns with fraility in this patient? If so why?

Yes, I definitely have concerns with fraility for this patient; he has all of the criteria needed to diagnose this clinical syndrome including: unintentional weight loss of 10lb in the last year, self-reported exhaustion weakness based on grip strength, and slow walking speed, and low physical activity (Kennedy-Malone, Fletcher, & Martin-Plank, 2014). According to Kennedy-Malone, Fletcher, & Martin-Plank (2014),

Frailty is not synonymous with comorbidity or disability, but comorbidity is a risk factor for frailty, and disability is an outcome of frailty. Frailty has been defined as a clinical syndrome when three or more of the following criteria are present: unintentional weight loss of 10 lb in the past year, self-reported exhaustion, weakness based on grip strength, slow walking speed, and low physical activity (Fried et al., 2001). It is important to understand frailty in order to develop accurate assessments, help patients and families with anticipatory planning, and make appropriate decisions about interventions and treatment (p. 616).

  1. What referrals should be made if any on this patient?

A referral to Physical Therapy (PT) and Occupational Therapy (OT) should be made for this patient (Harrison, Clegg, Conroy, & Young, 2015). These therapies will assist the patient in improving his mobility and physical function as well as improving his performance for the activities of daily living (Harrison, Clegg, Conroy, & Young, 2015). A referral should also be made to Speech Therapy (ST) to ensure that the patient does not difficulty with swallowing which may be contributing to his weight loss. I would also refer the patient to a Registered Dietician to ensure the patient is getting the appropriate nutrition and also to advise on any supplements that may help the patient with his weight loss. A referral to a dentist may be necessary if the patient has ill-fitting dentures to ensure the patient is able to properly chew his food to maintain nutrition (Goolsby & Grubbs, 2015). A home assessment should be performed to ensure the patient can safely continue to stay at home independently and function as he has been (Goolsby & Grubbs, 2015).

References

British Columbia Guidelines. (2017). Fraility in Older Adults- Early Identification and Management. Retrieved from https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/frailty

Goolsby, M. J. & Grubbs, L. (2015). Advanced Assessment: Interpreting Findings and Formulating Differential Diagnoses (3rd ed.). Philadelphia, PA: F. A. Davis Company.

Harrison, J., Clegg, A., Conroy, S., Young, J. (2015). Managing frailty as a long-term condition. Age and Ageing. 44(5), 732–735.

Kennedy-Malone, L., Fletcher, K. & Martin-Plank, L. (2014). Advanced Practice Nursing in the Care of Older Adults. F.A. Davis: Philadelphia, PA.

Smets, I. H., Kempen, G. I., Janssen-Heijnen, M. L., Deckx, L., Buntinx, F. J., & Van Den Akker, M. (2014). Four screening instruments for frailty in older patients with and without cancer: a diagnostic study. BMC Geriatrics, 14, 26.

Discussion 2:

You are evaluating a 78 year old white male who comes to your office today with unintentional weightloss of 10lb in the last year, self-reported exhaustion weakness based on grip strength, and slow walking speed, and low physical activity. Notes that he has been feeling worse over the past 6 monthsand just does not have the strength to do anything anymore. The patient states they are not currently on any medications except a multivitamin. He notes that he lives alone and does not want to leave his house. Answer the following questions with supportive rationale:

  1. What questions should you as the patient/family to further assess?

Ask the client about any physical changes, body deformities, falls or traumas since weakness and decreased activity has been detected?

To accurately diagnose musculosketal dysfunction in the older adult the practitioner must familiarize themselves with age-associated changes. Decreased height, diminished trunk and extremity length, spine curvature, decreased muscle mass, loss of subcutaneous fat, and pronounced bony prominences are common. The loss or limitation of functional ability is often the motivator in the elderly to seek medical attention (Malone, Fletcher, Martin-Plank, 2014).

Determine the character of symptoms: whether they are constant, intermittent, localized or generalized?

Local weakness or paralysis may be attributed to pain or neurological deficits causing the client to limit use to avoid exacerbations. Generalized weakness can be caused by systemic disorders or recent deconditioning as a result of immobility or frailty (Malone, Fletcher, Martin-Plank, 2014).

Determine exacerbating and relieving factors of reported symptoms

Weakness of the muscles must be differentiated from subjective fatigue. Patient can be experiencing both such as with new onset of gout or a history of osteoarthritis of the joints ((Malone, Fletcher, Martin-Plank, 2014).

Ask about any previous medical diagnosis or medications and last physical?

Although the client is only taking a multivitamin, his past orthopedic and medical history is relevant in assessing his declining physical status. Any orthopedic surgeries, or medical diagnosis is important in determining if his physical limitations are due to systemic disease. Patients with underlying thyroid disorders may have chronic weakness, whereas generalized weakness is seen in conditions such as sarcopenia. Intermittent o weakness is common with rheumatoid arthritis (Malone, Fletcher, Martin-Plank, 2014).

Ask the client about performing routine care or activities of daily living (ADLs)?

Note weather he has difficulty grooming himself, lifting objects, standing after prolonged periods of sitting, fastening the buttons on his clothes or turning a doorknob. Proximal weakness is caused by myopathy, disorder of the muscles. Myopathy of distal extremities would cause trouble with leg crossing or walking. Distal weakness from neuropathy would cause problems with some fine motor skills such as buttons or zippers on clothing or opening jars or cans of food (Malone, Fletcher, Martin-Plank, 2014).

Ask about food intolerance and vision changes?

Weight loss in the elderly is often due to socioeconomic factors as well functional decline. Malnutrition can occur with anyone for a host of reasons, but adults over the age of 80 are at an increased risk. A weight loss of 5% or greater than a person’s baseline, inactivity, decreased appetite and impaired immune function are indicators of malnourishment (Santos-Eggimann & Sirven, 2016). The client’s fatigue and weakness are obvious factors, but poor vision and problems such as heartburn or acid reflux could be issues easily resolved. Vision would be a factor because the client lives alone and would have to prepare his own meals.

Ask about family support, social circles, and hobbies

The elderly are at risk for depression and social isolation (Malone, Fletcher, Martin-Plank, 2014).

2. What screening tools would be appropriate in this case?

  • Physical examination- begin by observing the patient gait. Any problems with gait or balance should be noted. Use the “Get Up and Go Test” to observe the client’s ability to go from a sitting to a standing position and note any difficulties Often with periods of inactivity the muscles stiffen and range of motion (ROM) is impaired as the person ages. When assessing ROM note any atrophy fasciculations, or fluttering of the muscles. Palpate for contraction of the muscle against resistance and compare each side. Flexor and extensor muscles should be tested and documented numerically (Malone, Fletcher, Martin-Plank, 2014).
  • Geriatric Depression Scale (GDS)- a 15 item self-reporting survey in yes/no format to screen for depression. It can be completed in 7 minutes or less, which makes it an effective screening tool for the elderly (American Psychological Association, 2018). Multiple experts and analyses suggests depression, cognition, and frailty all belong to the same construct (Santos-Eggimann & Sirven, 2016).
  • Fried’s frailty Phenotype- based on a 5 item assessment to determine frailty. The items include shrinking, weakness, slowness, exhaustion, and low activity. Frail clients score 3/5, intermediates score 2/5, and zero would cary no risk factors. Frailty is a progressive but possibly preventable health deficit when screening is used (Santos-Eggimann & Sirven, 2016).

3. Do you have concerns with fraility in this patient? If so why?

The 78-year-old client meets 5/5 of Fried’s frailty inclusion criteria. He has weakness, low activity, easily exhaustion and shrinking. Shrinking is characterized by weight loss, low grip strength, slowed walking, and self-reported fatigue (Santos-Eggimann & Sirven, 2016).

4. What referrals should be made if any on this patient?

  • For patients with malnutrition, evaluate the need for a speech therapy assessment if dysphagia is present
  • refer to physical and occupational therapy, modify environment, and provide assistive devices.
  • Clinical coordinator for home health agency-environmental modifications to enhance socialization and stimulate appetite, end-of-life decisions, and caregiver support.
  • Provide any community support information (meals on wheels, community centers, local YMCA)- combat depression, engage in social activities
  • Referral for psychosocial counseling-the five indicators proposed by Fried et al. are likely to reflect mental health as well: weight loss, fatigue and low physical activity are observed in depression and dementia; fatigue is measured by items from a depression screening too(Santos-Eggimann & Sirven, 2016).

Geriatric Depression Scale (GDS). (2018). Retrieved from

http://www.apa.org/pi/about/publications/caregiver

Kennedy-Malone, L. Fletcher,K., Martin-Plank, L. (2014) Advanced Practice Nursing in the Care of

older adults. Philadelphia, PA: F. A. Davis Company. Retrieved from

from https://digitalbookshelf.southuniversity.edu/#/books/9780803641242/cfi/6/2!/4/4/6@0:1

Santos-Eggiman, B., Sirven, N. (August, 2016). Screening for frailty: Older populations and

older individuals. Public Health Reviews 37(7). Retrieved from

https://doi.org/10.1186/s40985-016-0021-8

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