Symptoms, Nutrition, Pressure Ulcers, and Return to Community Among Older Women

Symptoms, Nutrition, Pressure Ulcers, and Return to Community Among Older Women Symptoms, Nutrition, Pressure Ulcers, and Return to Community Among Older Women Symptoms, Nutrition, Pressure Ulcers, and Return to Community Among Older Women With Heart Failure at Skilled Nursing Facilities A Pilot Study _201801000_00005.pdf critique_worksheet.p Journal of Cardiovascular Nursing Vol. 33, No. 1, pp 22Y29 x Copyright B 2018 Wolters Kluwer Health, Inc. All rights reserved. Symptoms, Nutrition, Pressure Ulcers, and Return to Community Among Older Women With Heart Failure at Skilled Nursing Facilities A Pilot Study Susan J. Pressler, PhD, RN; Miyeon Jung, PhD, RN; Marita Titler, PhD, RN; Jordan Harrison, PhD, RN; Kayoung Lee, MSN, RN Background: Mortality rate is high for older women with heart failure (HF) who are discharged to skilled nursing facilities (SNFs) after hospitalization, but little is known about their symptoms, nutritional factors, and pressure ulcer status and whether these variables predict the women’s return to the community. Objectives: The aims of this study are to characterize symptoms (ie, dyspnea, cognitive dysfunction, depression, and pain) and nutritional and pressure ulcer status, evaluate relationships among symptoms, and examine predictors of return to the community among older women with HF admitted to SNFs. Methods: In this pilot observational study, data were collected retrospectively from the electronic medical records and the Minimum Data Set 3.0. Results: Data were obtained for 45 women with HF (mean age, 84.8 years). Frequency of symptoms was dyspnea 18%, cognitive dysfunction 20%, depression 5%, and pain 78%. Mean body mass index (BMI) was 29.8 kg/m2. Frequency of pressure ulcer risk was 85% and 18% had pressure ulcers. The 4 symptoms were not significantly related. Younger age (odds ratio, 0.90; P = .023) and BMI of 25 kg/m2 or greater (odds ratio, 5.31; P = .017) predicted return to the community. Conclusions: The women in this study had frequent pain, moderately frequent cognitive dysfunction, and high pressure ulcer risk. Surprisingly, few women had dyspnea or depression. Women who were younger with higher BMI were more likely to return to the community. The study needs to be replicated in a larger more diverse group of older patients with HF. KEY WORDS: aged, heart failure, signs and symptoms, skilled nursing facilities, women M ore than 5.7 million Americans have heart failure (HF), a disabling chronic condition associated with high rates of mortality, hospitalization, and troubling symptoms that decrease quality of life.1 In an Susan J. Pressler, PhD, RN Professor and Sally Reahard Endowed Chair, Indiana University School of Nursing, Indianapolis. Miyeon Jung, PhD, RN Postdoctoral Fellow, Indiana University School of Nursing, Indianapolis. Marita Titler, PhD, RN Professor and Rhetaugh Dumas Endowed Chair, University of Michigan School of Nursing, Ann Arbor. Jordan Harrison, PhD, RN University of Michigan School of Nursing, Ann Arbor. Kayoung Lee, MSN, RN PhD Candidate, University of Michigan School of Nursing, Ann Arbor. Funding sources: University of Michigan Institute for Women and Gender; Indiana University School of Nursing Center for Enhancing Quality of Life in Chronic Illness. The authors have no conflicts of interest to disclose. Correspondence Susan J. Pressler, PhD, RN, Indiana University School of Nursing, 600 Barnhill Drive, Indianapolis, IN 46202 ([email protected]). DOI: 10.1097/JCN.0000000000000422 observational study that linked patient registry and Centers for Medicare and Medicaid Services claims data of 15 459 older HF patients hospitalized at 149 different sites, 24.1% were discharged to skilled nursing facilities (SNFs).2 Characteristics associated with discharge to SNFs were longer hospital stay, older age, female gender, hypotension, increased left ventricular ejection fraction indicating preserved ejection fraction, nonischemic HF, and certain comorbidities (history of depression and stroke). Symptoms, Nutrition, Pressure Ulcers, and Return to Community Among Older Women Most patients were receiving medications as recommended in national practice guidelines for HF. Notably, 30 days after hospital discharge, patients discharged to SNFs had higher rates of death (14.4% vs 4.1%, P G .001) and rehospitalization (27.0% vs 23.5%, P G .001) compared with patients not discharged to these facilities. Twelve months after hospital discharge, patients discharged to SNFs continued to have higher rates of death (53.6% vs 29.1%, P G .001) and rehospitalization (76.1% vs 72.2%, P G .001) compared with patients not discharged to SNFs. To better understand the poor outcomes of HF patients cared for at SNFs, Jung and colleagues3 conducted 22 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Return to Community Among Women With Heart Failure 23 an integrated literature review of Medline, CINAHL, PubMed, and Google Scholar to evaluate studies published from 1965 to June 30, 2011. The search yielded 29 data-based studies. Twenty-four of these studies were retrospective or used existing databases and 5 were prospective (3 observational, 2 interventions). The studies reported factors associated with hospital readmission from SNFs (n = 6), hospitalization trends (n = 3), hospital discharge to postacute care settings (n = 12), rehabilitation services provided in postacute care settings (n = 5), cost of postacute services (n = 1), and postacute care interventions (n = 2).3 The 2 intervention studies reported results from a pilot study of a telehealth intervention to deliver skilled nursing care to 24 patients with HF, chronic obstructive pulmonary disease, and/or chronic wounds4 and a randomized controlled trial in which investigators tested the efficacy of an HF educational program for staff at SNFs.5 Recently, Chamberlain and colleagues6 examined the association between selfrated health and SNF admission among 417 HF patients residing in the community. Patients completed the Short-Form Health Survey as part of the study, and the first item, which assesses self-rated health (‘‘In general, would you say your health is: Excellent, Very Good, Good, Fair, Poor’’), was used in analysis. Self-rated health was not associated with SNF admission in this sample. No past studies have reported symptoms, nutritional factors, or pressure ulcer status among HF patients in SNFs despite these being common problems that can be targeted for interventions to decrease mortality and morbidity and improve health-related quality of life. Patients with HF frequently experience dyspnea,1 cognitive dysfunction,7 depression,8 and pain.9 In addition, they experience poor nutrition because of lack of compliance with dietary sodium restrictions10; weight loss and malnutrition11; and increased pressure ulcer risk12 because of poor peripheral circulation,1 malnutrition,11 and limited mobility.1 In 2015, the American Heart Association and the Heart Failure Society of America issued a scientific statement about management of HF in SNFs.13 The authors of the statement noted that empirical data are lacking about HF care in SNFs and more research is needed to guide management of these patients. Most past studies have focused on HF patients who were hospitalized in acute care facilities or living at home. Much less is known about symptoms, nutritional factors (ie, body mass index, weight gain and loss, and adherence to dietary sodium restrictions), and pressure ulcer status among older women with HF who reside in SNFs. In summary, past studies about HF patients residing in SNFs reported that they have increased mortality and hospital readmission.2 However, no studies reported symptoms and nutritional and pressure ulcer risks, even though these are common problems in HF and are amenable to interventions. In addition, it is unknown whether they predict patients’ return to the community after SNF stay. Furthermore, no studies focused on older women with HF in SNFs. Symptoms, Nutrition, Pressure Ulcers, and Return to Community Among Older Women ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Therefore, the aims of this observational pilot study are to (1) characterize the frequency and severity of dyspnea, cognitive dysfunction, depression, and pain; nutritional factors of body mass index; weight gain and loss; adherence to dietary sodium restrictions; and pressure ulcer status among older women (age Q65 years) with HF admitted to SNFs; (2) evaluate the relationships among dyspnea, cognitive dysfunction, depression, and pain; and (3) examine symptoms, nutritional factors, and pressure ulcer status as predictors of return to the community after SNF stay. Methods Design and Procedures An observational design was used with retrospective data collection. The design was appropriate to describe the frequency and severity of symptoms, nutritional factors, and pressure ulcer risk among women with HF in SNFs; examine whether these variables predict return to the community; and generate hypotheses for future larger prospective studies.14 The study was approved by the university institutional review board and the healthcare corporation to which the SNFs belonged. The study sites were 4 SNFs in southeastern Michigan. All women in the SNFs who met the eligibility criteria were identified by a member of the healthcare corporation using the electronic medical records. Names and identification information were then provided to members of the study team. Data were collected from the medical records by members of the study team using structured data abstraction forms adapted from forms used in previous studies among HF patients.15,16 One investigator with expertise in data abstraction (SJP) completed all data collection with assistance from 2 coinvestigators (JH and MJ). Data were entered into the SPSS statistical database and verified before analysis. Sample The sample was 45 older women with a diagnosis of HF. Inclusion criteria were (1) medical diagnosis of HF by International Classification of Diseases (ICD-9) codes (428.0, 428.30, or 428.9), (2) female sex, (3) 65 years or older, (4) admission Minimum Data Set, Version 3.017 data available, and (5) admitted to the SNFs between June 2014 and September 2014. Measures Demographic characteristics (ie, age, race, ethnicity, and marital status) and clinical variables (ie, number of comorbid medical diagnoses by ICD-9 codes upon Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. 24 Journal of Cardiovascular Nursing x January/February 2018 SNF admission, medications, height, weight, admission vital signs and oxygen saturation) were abstracted to describe the sample. Length of SNF stay and discharge disposition (community [home, assisted living, senior living], hospital, hospice, or death while in the SNF) were collected. Symptoms (ie, dyspnea, cognitive dysfunction, depression, and pain), nutritional factors (ie, body mass index, weight gain and loss, and adherence to dietary sodium restrictions), and pressure ulcer status were measured using data documented in the Minimum Data Set, Version 3.017 and medical records within the first 2 weeks of admission to the SNF. The Minimum Data Set, Version 3.0 is a standardized assessment form developed to improve assessment of symptoms and clinical conditions and care management among residents at nursing homes and strengthen communication among residents, family members, and healthcare providers.17 The validity and reliability of the Minimum Data Set, Version 3.0 items have been documented among a national sample of nursing home staff and residents.17 Dyspnea was measured using data documented in the Minimum Data Set, Version 3.0 Section J, Health Conditions.17 The resident was requested to select from 4 items about whether she had shortness of breath within the past 5 days with exertion (eg, walking, bathing), sitting at rest, lying flat, or had no shortness of breath. Possible scores range from 0 to 3, and a higher score indicates shortness of breath when in different positions (at rest or lying flat) and with activities (ie, exertion). Developers of the Minimum Data Set, Version 3.0 obtained interrater reliabilities and feedback for the shortness-of-breath items.17 Interrater reliabilities were . = 0.99 (research nurses) and 0.96 (research and nursing home nurses) and 96% of respondents believed the definitions were clear. Cognitive dysfunction was measured by the Brief Interview for Mental Status,18 which is part of the Minimum Data Set, Version 3.0 Section C, Cognitive Patterns.17 It is a 10-item questionnaire that requires participants repeat 3 words; answer 3 items about orientation to month, day, and year; recall the 3 words in the first item; and answer 3 questions about organized thinking. Symptoms, Nutrition, Pressure Ulcers, and Return to Community Among Older Women A summary score ranges from 0 to 15, with higher scores indicating better mental status. Scores lower than 13 indicate likely cognitive impairment.17 To support validity, the Brief Interview for Mental Status was correlated with the Modified MiniMental State among a national validation sample of 418 nursing home residents (r = 0.91, P G .001).17 For scores suggesting any cognitive impairment (12 or less), sensitivity was 0.83 and specificity was 0.91, and for scores suggesting severe cognitive impairment (7 or less), sensitivity was 0.83 and specificity was 0.92 among 375 nursing home residents.17,19,20 Depression was measured using the Patient Health Questionnaire-9,21 which is part of the Minimum Data Set 3.0 Section D, Mood.17 Items on the Patient Health Questionnaire-9 were based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria for depression. The Patient Health Questionnaire-9 is composed of 9 items that ask how often over the past 2 weeks an individual has been bothered by each of the 9 problems (0 = ‘‘not at all’’ to 3 = ‘‘nearly every day’’). Possible scores range from 0 to 27, and higher scores indicate greater likelihood of depression. Scores of 10 or more indicate likely depression.22 Validity and reliability of the Patient Health Questionnaire-9 have been documented among HF patients.23 Pain was measured using data documented in the Minimum Data Set, Version 3.0 Section J Health Conditions, Pain Intensity,17 and medical records. The resident was asked if she had pain and, if yes, was then asked to rate the intensity of pain in the past 5 days. From the Minimum Data Set questions, the resident could choose to rate the pain on a verbal descriptor or numeric rating scale, whichever she preferred. The verbal descriptor scale responses are 1 = ‘‘mild’’; 2 = ‘‘moderate’’; 3 = ‘‘severe’’; 4 = ‘‘very severe, horrible’’; and 9 = ‘‘unable to answer or not attempted.’’ Possible scores range from 1 to 4 and a higher score indicates more severe pain. From the medical records, the numeric rating scale was completed by showing the resident the 0 to 10 scale and telling her to rate the pain with ‘‘zero being no pain and ten as the worst pain you can imagine.’’ Possible scores range from 0 to 10 and a higher score indicates more severe pain. Validity and reliability have been documented for both the verbal descriptor and the numeric rating scales.24,25 Nutritional factors were measured using admission data (for body mass index) and Minimum Data Set, Version 3.0 Section K, Swallowing/Nutritional Status.17 In this section, the resident was asked whether she had weight loss of 10% or more in the past month or 5% or more in the past 6 months, with responses being no/unknown and yes, and whether she had received a therapeutic diet (eg, low salt, diabetic) before admission to SNF and while in SNF. Pressure ulcer status was measured using the Minimum Data Set 3.0 Section M, Skin Conditions.17 In this section, the resident was assessed as to whether she was at risk for a pressure ulcer, had a current pressure ulcer and, if so, the number and stage of the ulcers, if she had a healed pressure ulcer, and any skin treatments she was receiving in the SNF (eg, pressure reducing device for a chair, turning program, ulcer care). Risk of a pressure ulcer and absence or presence of a current pressure ulcer were used in the analysis. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Return to Community Among Women With Heart Failure 25 Statistical Analysis Descriptive statistics were computed for all study variables. Aim 1 was accomplished using descriptive statistics to characterize the frequency and severity of symptoms, nutritional factors, and pressure ulcer status. Symptoms, Nutrition, Pressure Ulcers, and Return to Community Among Older Women Aim 2 was accomplished using Spearman correlation coefficients26 to examine relationships among the 4 symptoms. Aim 3 was accomplished using t tests, Fisher exact test, and exact logistic univariate regression to examine predictors of return to community after SNF stay. Analyses were completed using SPSS. The significance level for all analyses was ! G .05. Results Demographic and clinical characteristics are shown in Table 1. The mean (SD) age of the 45 women was 84.8 (8.0) years and 73% were not married. The total number of medical diagnoses by ICD-9 codes was 220 across all women and the mean (SD) number of medical diagnoses per woman was 12.9 (4.6). The most common comorbidities were hypertension nonspecific (64%), difficulty in walking (62%), muscle weakness general (56%), hyperlipidemia (47%), and atrial fibrillation (44%). Most (84%) of the women were receiving diuretics, 38% were receiving angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and 60% were receiving “-adrenergic blocking agents. On average, vital signs were within normal limits upon admission. The mean (SD) oxygen saturation was 95.4% (2.5%). Frequency and severity of symptoms; nutritional factors of weight gain and loss, therapeutic diet, and body mass index; and pressure ulcer status are shown in Table 2. Frequency and severity of dyspnea were low. Thirty-six (82%) of the women reported no shortness of breath and 8 (18%) reported some shortness of breath. Six (14%) women reported shortness of breath with exertion, 1 (2%) reported shortness of breath when sitting, and 1 (2%) reported shortness of breath when lying flat. Frequency and severity of cognitive dysfunction were moderate. Eight (20%) women had scores lower than 13 and the mean (SD) Brief Interview for Mental Status score was 13.5 (2.7). Frequency and severity of depression were low. Two (5%) women had Patient Health Questionnaire-9 scores of 10 or higher and the mean (SD) score was 3.5 (2.8), indicating that the women reported few depressive symptoms. Frequency of pain was high, with 78% of women reporting pain within the past 5 days. Most women reported pain occasionally (57%) or frequently (23%). Severity of pain was moderate to high. Among the 23 women who were assessed using the 0-to-10 numeric scale, the mean (SD) score was 4.7 (3.3). For nutritional factors, body mass index was high on average (29.8 T 9.2 kg/m2). Eight (27%) women reported following a therapeutic diet before SNF TABLE 1 Demographic and Clinical Characteristics (N = 45) Characteristic Age, mean T SD (median; range), y n (%) 84.8 T 8.0 (86; 66Y100) Race African-American 1 (2) White 44 (98) Ethnicity Hispanic 0 (0) Non-Hispanic 42 (93) Missing 3 (7) Marital status Married 10 (22) Not married 33 (73) Missing 2 (4) Number of comorbidity from ICD-9 codes, 12.9 T 4.6 (12; mean T SD (median; range) 5Y26) Most common comorbid conditions from ICD-9 Hypertension NOS 29 (64) Difficulty in walking 28 (62) Muscle weakness general 25 (56) Hyperlipidemia 21 (47) Atrial fibrillation 20 (44) Hypothyroidism 15 (33) Esophageal reflux 15 (33) COPD 13 (29) Anemia NOS 12 (27) Anxiety state NOS 11 (24) Unspecified vitamin deficiency 11 (24) HF medications ACE-inhibitor or ARB 17 (38%) “-adrenergic blocking agent 27 (60%) Diuretic 38 (84%) Vital signs at admission, mean T SD (median; range) Systolic blood pressure, mm Hg 126.1 T 16.0 (126.0; 102Y171) Diastolic blood pressure, mm Hg 65.8 T 11.4 (66.0; 41Y90) Pulse rate, beats per minute 79.6 T 12.8 (78.0; 60Y110) Respiratory rate, breaths per minute 18.1 T 2.5 (18.0; 10Y24) Temperature, degrees Fahrenheit (n = 44) 97.9 T 0.8 (97.9; 96.0Y100.6) Oxygen saturation at admission, 95.4 T 2.5 (96.0; mean T SD (n = 38), % 90Y99) Oxygen treatment Patients without supplemental oxygen 26 (76) Patients with supplemental oxygen 8 (24) …Symptoms, Nutrition, Pressure Ulcers, and Return to Community Among Older Women Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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