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CKD in the Long Term Care Setting

This presentation focuses on factors affecting elderly with CKD, comparing current long-term care and optimal care needs. Recognizing health care team roles is emphasized for elder CKD patients. Factors influencing the elderly's health like medical status, cognition, and environment are discussed, addressing challenges in nursing homes like privacy and care quality. Considerations for long-term care settings are highlighted, covering aspects such as environment cleanliness, meal quality, and healthcare services, ensuring comprehensive care for the elderly with CKD.

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CKD in the Long Term Care Setting

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  1. CKD in the Long Term Care Setting Presented by: Mujan Noroozian, UTMB Dietetic Intern Department of Nutrition & Metabolism http://www.cliparthut.com/cartoon-kidney-clipart.html

  2. Objective • At the end of this presentation, you will be able to • identify the factors that affect the elderly with CKD • compare the current long term care available for the elderly versus what is necessary for optimal care • recognize the different health care team members needed to treat elderly CKD patients, in particular, nurses (RN) and dietitians (RD)

  3. Top Eight Leading Causes of Death for Adults >65 years Dorner, B., & American Dietetic Association. (2010). Position of the american dietetic association: Individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc, 110(10), 1549-1553. doi:10.1016/j.jada.2010.08.022

  4. Risk Factors of CKD • Age • HTN • Diabetes • Liver Disease • Vascular Disease • Hypovolemia • Nephrolithiasis • Infections • Medications (i.e. NSAIDs) Beto, J. A., & Bansal, V. K. (2004). Medical nutrition therapy in chronic kidney failure: Integrating clinical practice guidelines. Journal of the American Dietetic Association, 104(3), 404-409. doi:10.1016/j.jada.2003.12.028

  5. Those at Highest Risk • Elderly patients in rehabilitation and long term care facilities most often have renal failure, whether it be acute or chronic. • Diabetics • Those with HTN • Minorities Beto, J. A., & Bansal, V. K. (2004). Medical nutrition therapy in chronic kidney failure: Integrating clinical practice guidelines. Journal of the American Dietetic Association, 104(3), 404-409. doi:10.1016/j.jada.2003.12.028

  6. Factors Affecting the Elderly • Medical/Health Status • Chronic or acute illnesses • Sensory changes: taste, smell, appearance, texture • Oral health • Medication use Dorner, B., & American Dietetic Association. (2010). Position of the american dietetic association: Individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc, 110(10), 1549-1553. doi:10.1016/j.jada.2010.08.022

  7. Factors Affecting the Elderly http://jennygardiner.net/blog/?tag=aging • Physical/Functional Status • Physical limitations • Balance • Physical strength /endurance • Physical activity Dorner, B., & American Dietetic Association. (2010). Position of the american dietetic association: Individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc, 110(10), 1549-1553. doi:10.1016/j.jada.2010.08.022

  8. Factors Affecting the Elderly • Cognition • Mental status change • Depression • Emotional needs • Nutrition/health beliefs Dorner, B., & American Dietetic Association. (2010). Position of the american dietetic association: Individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc, 110(10), 1549-1553. doi:10.1016/j.jada.2010.08.022

  9. Factors Affecting the Elderly • Environmental • Living situation • Economics • Lifestyle • Access to food and food preparation • Socialization • Religious/cultural beliefs and traditions Dorner, B., & American Dietetic Association. (2010). Position of the american dietetic association: Individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc, 110(10), 1549-1553. doi:10.1016/j.jada.2010.08.022

  10. Common Nursing Home Problems • Lack of privacy • Poor quality of care • Neglect and abuse • Infections • Inexperienced staff • High turnover in staff members • Small ratio of staff members to residents Assisted living and nursing home issues: http://www.cobar.org/repository/Public_Docs/slh/21_Assisted_Living_and_Nursing_Home_Issues.pdf. Accessed July 19, 2015.

  11. Considerations for the Elderly in Long Term Care • Environment • Is the environment clean, well maintained, relaxed, friendly • Are there safe, accessible walking paths • Are there safety devices (fire alarms, sprinklers) • Are the dining rooms pleasant Nursing homes (skilled nursing facilities): http://www.merckmanuals.com/home/older-people-s-health-issues/provision-of-care-to-older-people/nursing-homes. Accessed July 20, 2015.

  12. Considerations for the Elderly in Long Term Care • Meals • Times that meals are served • Are meals served hot • Are meals nutritious and do they taste good • Are snacks available between meals • Can meals be provided in resident’s room • Are the dining rooms easily accessible for residents • Can the nursing home provide special diets and special textures • Are staff members available and able to help with feeding a resident Nursing homes (skilled nursing facilities): http://www.merckmanuals.com/home/older-people-s-health-issues/provision-of-care-to-older-people/nursing-homes. Accessed July 20, 2015.

  13. Considerations for the Elderly in Long Term Care • Health Care • Therapy programs (physical, occupational, speech therapy) • How prescription drugs are ordered and given • How use of drugs are monitored • Other health care practitioners (dentists, dietitians, optometrists, social workers, counselors) • Transportation to and from physician’s office Nursing homes (skilled nursing facilities): http://www.merckmanuals.com/home/older-people-s-health-issues/provision-of-care-to-older-people/nursing-homes. Accessed July 20, 2015.

  14. Dialysis Care Team Nephrologist (MD) Nurse Practitioner (NP) or Physician Assistant (PA) Nephrology Nurse (RN) Renal Dietitian (RD, CSR) Nephrology Social Worker National Kidney Foundation. (2015). Clinical practice guidelines for chronic kidney disease. www.kidney.org. Accessed July 9, 2015.

  15. Dialysis Care Team 6. Patient Care Technician (PCT) 7. Biomedical Technician 8. Vascular Access Surgeon 9. Radiologist 10. Access Coordinator National Kidney Foundation. (2015). Clinical practice guidelines for chronic kidney disease. www.kidney.org. Accessed July 9, 2015.

  16. Nursing Care Planning • Monitoring blood pressure • Monitoring fluid/electrolyte status • Checking daily weights (especially in the mornings) • Checking & being knowledgeable about the patient’s access (fistulas, catheters) A day in the life of a renal nurse: http://www.istudentnurse.com/dialysis. Accessed July 21, 2015.

  17. Nursing Care Planning • Care for Hemodialysis (HD) • Monitor BP and pulse at least every 30 minutes • Obtain weight before & after HD • May need to infuse drugs via medication port during dialysis • Obtain blood samples (urea nitrogen, creatinine, electrolytes) • Monitor for hypotension • Monitor fluid volume status A day in the life of a renal nurse: http://www.istudentnurse.com/dialysis. Accessed July 21, 2015.

  18. Nursing Care Planning • Care for Peritoneal Dialysis (PD) • Maintain sterile technique • Prevent infections • Record fluid intake and output • Record patient’s weight before & after procedure • Promote dialysate drainage at the proper speed A day in the life of a renal nurse: http://www.istudentnurse.com/dialysis. Accessed July 21, 2015.

  19. Things for All Staff to Consider for CKD Residents General medical care of patients on dialysis: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/general-medical-care-of-patients-on-dialysis/Default.htm. Accessed July 21, 2015.

  20. Things for All Staff to Consider for CKD Residents General medical care of patients on dialysis: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/general-medical-care-of-patients-on-dialysis/Default.htm. Accessed July 21, 2015.

  21. Things for All Staff to Consider for CKD Residents General medical care of patients on dialysis: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/general-medical-care-of-patients-on-dialysis/Default.htm. Accessed July 21, 2015.

  22. Things for All Staff to Consider for CKD Residents General medical care of patients on dialysis: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/general-medical-care-of-patients-on-dialysis/Default.htm. Accessed July 21, 2015.

  23. Things for All Staff to Consider for CKD Residents General medical care of patients on dialysis: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/general-medical-care-of-patients-on-dialysis/Default.htm. Accessed July 21, 2015.

  24. Things for All Staff to Consider for CKD Residents General medical care of patients on dialysis: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/general-medical-care-of-patients-on-dialysis/Default.htm. Accessed July 21, 2015.

  25. Things for All Staff to Consider for CKD Residents General medical care of patients on dialysis: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/general-medical-care-of-patients-on-dialysis/Default.htm. Accessed July 21, 2015.

  26. General Nutritional Management • Weight History • Chewing/swallowing • Feeding ability • Diet order • Labs

  27. General Nutritional Management • Fluid restrictions • Educational needs • Nutrient needs http://www.lirebon.com/health/multiple-micronutrient-supplement http://inmyskinnygenes.com

  28. Nutritional Management for Long Term Care • In addition to general nutrition management, we want to assess and consider patients for, • Liberalized diet • Supplements • N/V • Loss of appetite • C/D http://www.canadiangirlruns.com/2015/01/lets-talk-about-vitamins/

  29. Nutritional Management for Long Term Care • Edema • High BP • High weight gain between dialysis treatments • Education

  30. Nutritional Challenges for CKD Patients in Nursing Home • May only have one CKD diet option • Special diets not always available • Meal times not always flexible • -meals may be missed during dialysis treatment • Poor food quality • No substitution options for food items Hulsebus-Colvin, J. (2015). The nutrition needs of patients with chronic kidney disease in health care community settings. Journal of Renal Nutrition: The Official Journal of the Council on Renal Nutrition of the National Kidney Foundation, 25(4), e31-e36. doi:10.1053/j.jrn.2015.04.004

  31. Nutritional Challenges for CKD Patients in Nursing Home • Protein needs may not coincide with protein in meals served • Mediocre food quality • Limited nutritional supplements in formulary • Items that are low sodium in menu may contain potassium • May not be giving phosphorus binders to patients • Orange juice, Milk of Magnesia, and Prune juice may be given to patients Hulsebus-Colvin, J. (2015). The nutrition needs of patients with chronic kidney disease in health care community settings. Journal of Renal Nutrition: The Official Journal of the Council on Renal Nutrition of the National Kidney Foundation, 25(4), e31-e36. doi:10.1053/j.jrn.2015.04.004

  32. Nutritional Needs: Non-Dialysis McCann L, ed. Pocket Guide to Nutritional Assessment of the Patient with Chronic Kidney Disease. 4th ed. New York, NY: National Kidney Foundation Council on Renal Nutrition; 2009.

  33. Nutritional Needs: Non-Dialysis Byham-Gray L, Stover, J, Wiesen K. A Clinical Guide to Nutrition Care in Kidney Disease. 2nd ed. Chicago, Ill: American Dietetic Association; 2013.

  34. Biochemical Parameters for CKD Byham-Gray L, Stover, J, Wiesen K. A Clinical Guide to Nutrition Care in Kidney Disease. 2nd ed. Chicago, Ill: American Dietetic Association; 2013.

  35. Financial Help for Treatment of Kidney Failure Federal Medicare Part A (hospital): covers inpatient care, kidney transplantation, skilled nursing home residence, and hospice care. Medicare Part B (outpatient): covers most dialysis treatments and supplies, health care provider fees, and anti-rejection medications for transplant. Medicare Part D (medications) Financial help for treatment of kidney failure: http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/financial-help-for-treatment-of-kidney-failure/Pages/facts.aspx. Accessed July 14, 2015.

  36. Financial Help for Treatment of Kidney Failure • Federal • Social Security Disability Insurance (SSDI) • Supplemental Security Income (SSI) Financial help for treatment of kidney failure: http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/financial-help-for-treatment-of-kidney-failure/Pages/facts.aspx. Accessed July 14, 2015.

  37. Financial Help for Treatment of Kidney Failure • State • Medicaid • Medigap (Medicare Supplement) • Medicare Savings Program • Kidney Specific State Assistance Programs • State Health Insurance Assistance Program (SHIP) Financial help for treatment of kidney failure: http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/financial-help-for-treatment-of-kidney-failure/Pages/facts.aspx. Accessed July 14, 2015.

  38. Financial Help for Treatment of Kidney Failure • Special Populations • U.S. Department of Veterans Affairs (VA) • Military Service Members, Retirees, and Families: TRICARE for Life • American Indians/Alaska Natives: The Indian Health Service • Children: The Children’s Health Insurance Program (CHIP) • People with Disabilities: Disability.gov Financial help for treatment of kidney failure: http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/financial-help-for-treatment-of-kidney-failure/Pages/facts.aspx. Accessed July 14, 2015.

  39. Financial Help for Treatment of Kidney Failure • Private Organizations • American Kidney Fund • -gives small grants to U.S. dialysis and transplant patients based on need. • National Kidney Foundation • -may help with nutrition, transportation, medications, and scholarships. Financial help for treatment of kidney failure: http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/financial-help-for-treatment-of-kidney-failure/Pages/facts.aspx. Accessed July 14, 2015.

  40. References • A day in the life of a renal nurse: http://www.istudentnurse.com/dialysis. Accessed July 21, 2015. • Assisted living and nursing home issues: http://www.cobar.org/repository/Public_Docs/slh/21_Assisted_Living_and_Nursing_Home_Issues.pdf. Accessed July 19, 2015. • Bernstein, M., Munoz, N., & Academy of Nutrition and Dietetics. (2012). Position of the academy of nutrition and dietetics: Food and nutrition for older adults: Promoting health and wellness. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS, 112(8), 1255-1277. doi:10.1016/j.jand.2012.06.015 • Beto, J. A., & Bansal, V. K. (2004). Medical nutrition therapy in chronic kidney failure: Integrating clinical practice guidelines. Journal of the American Dietetic Association, 104(3), 404-409. doi:10.1016/j.jada.2003.12.028 • Byham-Gray L, Stover, J, Wiesen K. A Clinical Guide to Nutrition Care in Kidney Disease. 2nd ed. Chicago, Ill: American Dietetic Association; 2013. • Dorner, B., & American Dietetic Association. (2010). Position of the american dietetic association: Individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc, 110(10), 1549-1553. doi:10.1016/j.jada.2010.08.022 • Financial help for treatment of kidney failure: http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/financial-help-for-treatment-of-kidney-failure/Pages/facts.aspx. Accessed July 14, 2015.

  41. References • General medical care of patients on dialysis: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/general-medical-care-of-patients-on-dialysis/Default.htm. Accessed July 21, 2015. • Hulsebus-Colvin, J. (2015). The nutrition needs of patients with chronic kidney disease in health care community settings. Journal of Renal Nutrition: The Official Journal of the Council on Renal Nutrition of the National Kidney Foundation, 25(4), e31-e36. doi:10.1053/j.jrn.2015.04.004 • Kamp, B., AmerSocNutr, AmerDietetAssoc, SocNutrEduc, American Society for Nutrition, Society for Nutrition Education, & American Dietetic Association. (2010). Position of the american dietetic association, american society for nutrition, and society for nutrition education: Food and nutrition programs for community-residing older adults. J Am Diet Assoc, 110(3), 463-472. doi:10.1016/j.jada.2009.12.009 • McCann L, ed. Pocket Guide to Nutritional Assessment of the Patient with Chronic Kidney Disease. 4th ed. New York, NY: National Kidney Foundation Council on Renal Nutrition; 2009. • National Kidney Foundation. (2015). Clinical practice guidelines for chronic kidney disease. www.kidney.org. Accessed July 9, 2015. • Nursing homes (skilled nursing facilities): http://www.merckmanuals.com/home/older-people-s-health-issues/provision-of-care-to-older-people/nursing-homes. Accessed July 20, 2015. • Tong, E. M., & Nissenson, A. R. (2002). DIALYZING THE ELDERLY: ISSUES AND CONCERNS: Dialysis in nursing homes. Seminars in Dialysis, 15(2), 103-106. doi:10.1046/j.1525-139X.2002.00033.x  • Twenty common nursing home problems and the laws to resolve them: http://www.commonwealthfund.org/publications/in-the-literature/2006/apr/twenty-common-nursing-home-problems-and-the-laws-to-resolve-them. Accessed July 14, 2015. • http://allnurses.com/geriatric-nurses-ltc/long-term-care-746461.html

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