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Semelhante a GR AFHS Cerumen Impaction 7-22.pptx
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GR AFHS Cerumen Impaction 7-22.pptx
- 1. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Grand Rounds NP Physician Topic: AFHS: Cerumen Impaction in the Older Adult Feel free to chat in the chat box. Remember to change your chat to ‘Everyone’ so we may all benefit from your comments. To Unmute your line: Click on your screen and then the microphone at the top of screen. Then click Unmute Call Physician NP Mary McCormack APNC Lilia Pino APNC Aldo Calvo, MD John Braga, MD
- 2. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Providing Age-Friendly Care The goal is for all care with older adults to be Age-Friendly care, which: • Follows an essential set of evidence-based practices; • Causes no harm; and • Aligns with What Matters to the older adult and their family caregivers. AFHS-specific Grand Rounds cases focus on the 4Ms Framework as it pertains to patients 65 years of age and older What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each case scenario. The 4Ms include: • What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences • Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation • Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults • Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that older adults move safely in order to maintain function and do What Matters
- 3. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. How to Integrate 4Ms Care into the Clinic Visit What Matters: These are some guiding questions or statements to help patients discuss what matters most to them: • What is most important for you during today’s visit? • What are you looking forward to this week? • What activities do you enjoy? If applicable, can ask: What is preventing patient from accomplishing tasks or participating in activities? • During development of care plan: I would like to individualize your treatment with what matters most to you Medication • Ask about all prescriptions: prescribed, over-the-counter, laxatives, vitamins, supplements, herbal remedies • Reconcile medications with electronic health record • Cross-check for medications that may be on the AGS Beers© Criteria list Mentation • Assess patient’s ability to register, use kiosk, follow directions • Screen for depression using the PHQ-2© and, if positive, continue with the PHQ-9© • Screen for dementia using the Mini-Cog™ • Assess for delirium for any acute change in mental status using the Confusion Assessment Method Mobility • Assess mobility, gait, gait speed, balance, footwear beginning when the patient walks in using the Modified Get Up and Go test • Assess hand dexterity, fine motor movements as patient removes insurance cards from wallet or writes or signs name
- 4. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Learning Objectives At the end of this session, providers will be able to: • Identify the interrelationship of the 4Ms in the context of an acute or chronic condition, such as cerumen impaction • Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over
- 5. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Case Scenario: Cerumen Impaction (S) Situation: John is a 78 year old male at the clinic to remove cerumen in ear. He just left his audiologist who recommended cerumen removal. John is accompanied by his part-time aide who drives him to appointments. His only other concern is difficulty falling asleep about three nights a week and on those nights he takes zolpidem which helps him fall asleep. What Matters most to John is being able to hear the bidding during the weekly bridge games in his assisted living facility. (B) Background: PMH: Hypertension, hyperlipidemia, bilateral knee replacement 5 years ago, insomnia Medications: lisinopril 20mg PO daily, rosuvastatin 20mg PO daily at bedtime, zolpidem 5mg PO at bedtime PRN insomnia. No known drug allergies. Reviewed labs drawn 6 months ago. Renal function: no abnormalities noted, Glucose 90 mg/dL, potassium 3.8 mEq/L, eGFR >60 mL/min/1.73m2, Lipid panel: Total Cholesterol 180 mg/dL, LDL 90 mg/dL Social: Past smoker, reports rare alcohol use, enjoys playing bridge each week. John has been living alone in an assisted living facility since his wife passed away 1 year ago. Exercise limited to walking around the assisted living facility using his cane.
- 6. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Case Scenario: Cerumen Impaction (Cont.) (A) Assessment: VS: BP 130/76 mmHg seated, HR 64/min, RR 18/min, Temp 98.5F, SpO2 98% on room air Mentation: Mood and dress appropriate, normal affect; PHQ-2 = 0 (negative); Mini-Cog = 5 (negative) Mobility: Assessed when the patient walked from the waiting area to the exam room. Used cane for ambulating. No difficulty walking or turning. Get Up and Go demonstrated no mobility, gait, or balance issues. Mouth and Neck: Moist mucous membranes; No lymphadenopathy Ears: Hearing aids both ears; dark brown, hardened cerumen bilaterally obstructing both tympanic membranes. Patient able to demonstrate appropriate use of hearing aids and knowledgeable regarding their maintenance. Respiratory: Lungs clear bilateral all lobes Cardiac: Regular rate and rhythm, S1, S2, no S3, S4, murmurs PV: Strong and equal dorsalis pedis pulses bilaterally; no edema (R) Recommendation: Let’s discuss…
- 7. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Recommendations…Back to the case… Summary: ASSESS and ACT ON the 4Ms as a set What Matters: Know and act on each patient’s specific health outcome goals and care preferences • Tailor treatment and follow up plan according to what matters most, which is to hear better and have cerumen removed • Bilateral cerumen impaction: Instill Debrox in both ears 2 times daily for 3 days; return for cerumen irrigation/removal Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters • Insomnia: Taking a sleep aid on AGS Beers Criteria© list; consider non-pharmacological management of insomnia (e.g. music, massage, relaxation therapy) • Consider polypharmacy and possibility for deprescribing (e.g. zolpidem) https://deprescribing.org Mentation: Focus on dementia and depression and delirium • Educate regarding cognitive stimulation such as puzzles, games, reading the newspaper, socialization • Patient widowed for one year; is active, social. No voiced concerns about mood or memory. Continue socialization. • Educate patient that sleeping medications may affect mentation and increase risk of new onset falls. Provide information on good sleep hygiene and non-pharmacologic measures that may help to promote sleep. Mobility: Maintain mobility and function and prevent/treat complications of immobility • Encourage daily mobility; Consider exercise program; Consider physical therapy • Discuss possibility of having the aide involved in providing support to increase activity and daily walking Provide 4Ms brochure with suggestions for patient/family to share with primary care provider, including recommendations to decrease risk of future cerumen impaction, hearing aid maintenance care, deprescribing zolpidem, reinforcing non-pharmacological strategies to manage insomnia, consideration of physical therapy
- 8. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Interprofessional Team Discussion…
- 9. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Acknowledgements Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA). MinuteClinic’s commitment to be an Age-Friendly Health System is supported by a grant from The John A. Hartford Foundation to the Case Western Reserve University Frances Payne Bolton School of Nursing.
- 10. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Thank You
Notas do Editor
- Today’s topic is: Cerumen Impaction in the Older Adult
- The goal is for all care with older adults to be Age-Friendly care, which follows an essential set of evidence-based practices, causes no harm, and aligns with What Matters to the older adult and their family caregivers. AFHS-specific Grand Rounds cases will focus on the 4Ms Framework as it pertains to our patients 65 years of age and older. What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each case scenario. The 4Ms include: What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that older adults move safely in order to maintain function and do What Matters
- This slide provides information to help integrate 4Ms care into the clinic visit. This is the basis of providing Age-Friendly care. You will become familiar with the Age-Friendly Health Systems 4Ms Framework logo. What Matters: These are some guiding questions or statements to help patients discuss what matters most to them: What is most important for you during today’s visit? What are you looking forward to this week? What activities do you enjoy? If applicable, can ask: What is preventing patient from accomplishing tasks or participating in activities? During development of care plan: I would like to individualize your treatment with what matters most to you Consider discussion about advance care planning if appropriate for the visit, likely not applicable for a cerumen impaction visit Medication Ask about all prescriptions: prescribed, over-the-counter, laxatives, vitamins, supplements, herbal remedies Reconcile medications with electronic health record Cross-check for medications that may be on the AGS Beers© Criteria list Mentation Assess patient’s ability to register, use kiosk, follow directions Screen for depression using the PHQ-2© and, if positive, continue with the PHQ-9© Screen for dementia using the Mini-Cog™ Assess for delirium for any acute change in mental status using the Confusion Assessment Method Mobility Assess mobility, gait, gait speed, balance, footwear beginning when the patient walks in using the Modified Get Up and Go test Assess hand dexterity, fine motor movements as patient removes insurance cards from wallet or writes or signs name
- At the end of this session, providers will be able to: Identify the interrelationship of the 4Ms in the context of an acute or chronic condition, such as cerumen impaction Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over
- S: Situation: John is a 78 year old male at the clinic to remove cerumen in ear. He just left his audiologist who recommended cerumen removal. John is accompanied by his part-time aide who drives him to appointments. His only other concern is difficulty falling asleep about three nights a week and on those nights he takes zolpidem which helps him fall asleep. What Matters most to John is being able to hear the bidding during the weekly bridge games in his assisted living facility. B: Background: PMH: Hypertension, hyperlipidemia, bilateral knee replacement 5 years ago, insomnia. Medications: lisinopril 20mg PO daily, rosuvastatin 20mg PO daily at bedtime, zolpidem 5mg PO at bedtime PRN insomnia. No known drug allergies. Reviewed labs drawn 6 months ago. Renal function: no abnormalities noted, Glucose 90 mg/dL, potassium 3.8 mEq/L, eGFR >60 mL/min/1.73m2, Lipid panel: Total Cholesterol 180 mg/dL, LDL 90 mg/dL Social: Past smoker, reports rare alcohol use, enjoys playing bridge each week. John has been living alone in an assisted living facility since his wife passed away 1 year ago. Exercise limited to walking around the assisted living facility using his cane.
- A: Assessment: VS: BP 130/76 mmHg seated, HR 64/min, RR 18/min, Temp 98.5F, SpO2 98% on room air Mentation: Mood and dress appropriate, normal affect; PHQ-2 = 0 (negative); Mini-Cog = 5 (negative) Mobility: Assessed when the patient walked from the waiting area to the exam room. Used cane for ambulating. No difficulty walking or turning. Get Up and Go demonstrated no mobility, gait, or balance issues. Mouth and Neck: Moist mucous membranes; No lymphadenopathy Ears: Hearing aids both ears; dark brown, hardened cerumen bilaterally obstructing both tympanic membranes. Patient able to demonstrate appropriate use of hearing aids and knowledgeable regarding their maintenance. Respiratory: Lungs clear bilateral all lobes Cardiac: Regular rate and rhythm, S1, S2, no S3, S4, murmurs PV: Strong and equal dorsalis pedis pulses bilaterally; no edema R: Recommendation: Let’s discuss…
- Age-Friendly health care seeks to incorporate all 4Ms (What Matters, Mobility, Medication, Mentation) into your assessment and provision of care of your patients 65 years of age and over. Here are some recommendations referring back to the case. Keep in mind the need to ASSESS and ACT ON the 4Ms as a set. What Matters: Know and act on each patient’s specific health outcome goals and care preferences Tailor plan according to what matters most to the patient, which is to hear better and have cerumen removed Plan is in place to treat bilateral cerumen impaction: Instill Debrox in both ears twice daily for 3 days; return for cerumen irrigation and removal Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters Insomnia: Taking a sleep aid on AGS Beers Criteria© list; consider non-pharmacological management of insomnia (e.g. music, massage, relaxation therapy) Consider polypharmacy and possibility for deprescribing (e.g. zolpidem). The website for deprescribing.org is provided: https://deprescribing.org Mentation: Focus on dementia and depression and delirium Educate regarding cognitive stimulation such as puzzles, games, reading the newspaper, socialization Patient widowed for one year; is active, social. No voiced concerns about mood or memory. Continue socialization. Educate patient that sleeping medications may affect mentation and increase risk of new onset falls. Provide information on good sleep hygiene and non-pharmacologic measures that may help to promote sleep. Mobility: Maintain mobility and function and prevent/treat complications of immobility Encourage daily mobility; Consider exercise program; Consider physical therapy Discuss possibility of having the aide involved in providing support to increase activity and daily walking Provide 4Ms brochure with suggestions for patient/family to share with primary care provider, including recommendations to decrease risk of future cerumen impaction, hearing aid maintenance care, deprescribing zolpidem, reinforcing non-pharmacological strategies to manage insomnia, consideration of physical therapy. Collaborate with interprofessional team members and primary care provider for follow up.
- Team discussion: NP, pharmacist, physician, other