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Nursing management review: Parkinsonism, hypertension, pneumonia.

Managing nursing home residents is becoming ever more clinically demanding. Due to the triple impact of OBRA, the rapid growth of the over-85 population and hospitals' "quicker and sicker" discharges, nursing staffs are under the gun. Their responsibilities for monitoring and managing residents are deepening in clinical sophistication. Recently NURSING HOMES asked two physicians with long experience in the nursing home setting to offer updated nursing care guidelines for conditions commonly experienced by nursing home residents. Consulted were:

Dennis W. Jahnigen, MD, Chief, Division of Geriatrics, The Cleveland Clinic Foundation, Cleveland, OH, and David Thomas, MD, Associate Professor of Medicine at the Bowman Gray School of Medicine and Medical Director of the Oak Summit Nursing Home, Winston-Salem, NC.

They addressed specific concerns with Parkinsonism, hypertension and pneumonia, as follows:


Dr. Jahnigen: "Of primary concern with Parkinsonism is its impact on resident autonomy and self-care. It is important to be aware of the psychological impact of this disorder and how demoralizing it is. Nursing should be supportive of self-care, such as bathing or brushing teeth, even if it takes more time than having the nurses simply do it themselves.

"Physical activity is very important to these patients, because they tend to be hypoactive and even vegetative. Programs of walking, assisted walking or wheelchair activities are all part of a good nursing care environment.

"As for monitoring anti-Parkinson medications, it's worth noting that, as a group, they rank second or third in incidence of psychiatric side effects. They have a major impact, for example, on incidence of delirium in the nursing home. The OBRA regulations have recommended drug holidays for all drugs that effect the central nervous system, and it might be helpful to apply that to anti-Parkinsonian medications, as well. Then it becomes the nurse's primary responsibility to report on all changes, or lack of change, observed in the resident with respect to onset of tremor, rigidity or bradykinesia, or psychiatric side effects."

Dr. Thomas: "Observing for the effects of the anti-Parkinsonian medications is a most important issue. At our facility we have special charting arrangements to track for the off-on phenomenon or the wearing-off effect, both of which occur particularly toward the terminal stages of the disease. We then monitor, of course, for the effects of any drug adjustments.

"While it is true that we tend to get the most severe cases of Parkinsonism in the nursing home, we also very frequently find ourselves initiating treatment for this disease. Either the diagnosis hasn't been made yet or drug therapy has been inadequate. This is largely because the physician and the family have not been in a position to monitor the patient closely enough. This is where the nursing home is superbly equipped to provide optimum care. Because of the opportunity it presents for close observation by professionally-trained nurses, we are able to prescribe and adjust drug therapy more accurately than was ever possible in the physician's office."


Dr. Thomas: "The critical issue here is the potential side effects of the antihypertensives, with orthostatic hypotension and dehydration being of particular concern. This assessment tends to take more nursing skill in the nursing home setting than in other settings, because residents' basic physical condition is so often compromised. Nursing home residents on antihypertensives need constant reassessment for side effects, and changes of drug are very common. Totally stopping drug therapy is also not uncommon in these patients.

"This may occur because of the physiology of aging. For example, some antihypertensives work by dilating the peripheral vasculature, but with the increasing autonomic dysfunction of aging, this tends to occur anyway, and may justify a therapeutic trial off the medication.

"In any event, you have to try to fit the drug therapy to the particular patient and his or her associated diseases. If, for example, there is associated angina, a calcium-channel blocker might be tried. If diabetes is present, there may be some benefit from an ACE-inhibitor because of its renal effects. In general, drug selection is keyed to associated diseases and vulnerability to specific side effects.

"Nurses have to be thoroughly familiar with the important side effects of all the antihypertensives and be ready to communicate these to the physician, because they have the closest personal contact with these patients of all health care professionals."

Dr. Jahnigen: "Aside from monitoring therapy with antihypertensive medications, nurses need to be alert for the possible usefulness of ancillary care, such as a low-salt diet or exercise to reduce systolic hypertension. They should be ready to recommend these if the physician hasn't already.

"An important consideration with the use of antihypertensives in this setting is that people in the nursing home tend to both reduce activity and to lose weight. Often, due to these factors, their previous drug regimens are no longer needed. Patients can be weaned off antihypertensives, and even cardiac drugs, simply because they've lost 10 to 15 pounds. That's why it is particularly important in the nursing home to be alert for signs of overmedication.

"Hypertensive effects should be continually monitored for, including blood pressures in both the supine and erect positions; some very severe drops can be detected in patients when they become ambulatory. Also, because of patients' tendency toward post-prandial hypotension, dosage times should be adjusted to avoid meal times. And, finally, specific side effects to watch for should be made a part of the care plan for any patient on these medications."


Dr. Jahnigen: "Most patients are qualified for Medicare coverage of hospital care for pneumonia, so the decision to treat this condition in the nursing home should be made very carefully. It should be based on what is best for the patient and what the facility's capabilities are for managing pneumonia, including availability of chest X-ray, blood gas testing, and resources for aggressive therapy, if appropriate. Ease of transfer to a hospital is another major consideration.

"If it appears that aggressive therapy would not be as appropriate as palliative care, then not only should all parties concerned be involved in this discussion, but nurses are particularly obliged to make sure that the decision is reasonable, because they are the health professionals who know the patient best."

Dr. Thomas: "Nursing assessment is critical in determining the severity of pneumonia and whether the facility is equipped to manage it. Though there are severity guidelines used by nurse practitioners and physician's assistants that might be available to nursing homes, the really difficult part of this for nurses is detecting whether or not these patients are really sick. The elderly often have very atypical presentations of pneumonia -- no fever, no purulent sputum, no elevated white cell count, they just seem "under the weather" in some nonspecific way. The challenge that this places on the nurses to be alert and responsiveness is equivalent to that posed by urinary tract infection, the other major infective disorder we see in this setting.

"Nurses have to also be responsible for monitoring the current status of any advanced directives in force, which is especially important these days with the requirement that residents undergo this discussion on admission. Even with an advanced directive in place, the patient has to be given the opportunity to change his or her mind. For some, after all, the nursing home is their home, and they may prefer to die in these surroundings rather than to be hospitalized and subjected to technology that may well prove to be futile. Because of their closeness to the patients, nurses should usually be the ones to initiate these discussions."
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Title Annotation:Nursing Care; interview with Dr. Dennis W. Jahnigen and Dr. David Thomas
Publication:Nursing Homes
Date:Apr 1, 1993
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