7 11% ''2549 40% Jitapankul, S 1998

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???????????????????????????????????????????
???? ???????????? 1. ???????????????????????
???????????????????? 2. ????????????
????????????????????????????
?????????? 3. ???????????????????????????????????
?????????????
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• ????????????? 7 ???? 11 ?.?.2549 ????????????
  ?? 40 (Jitapankul, S 1998)
• USA 13 1/3 of budget for health
• 42 of inpatient
• 60 of
  critical care
• 2 time Longer LOS
• 2 time more frequent
• (Fulmer 2002)

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Impact of a growing elder

• Budget
• Chronic ill .. costly

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??????????????????????? 1.
????????????????? (Care for the
older) 2. ?????????????????????????????
????????? (Geriatric Nursing)
3. ????????????????????????????????
(Research in the field)
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??????????????????????? 4.
??????????????????????????? (Ethics)
5. ???????????????????????????????????
(Advanced Practice Nurse) 6.
???????????????? (Long Term care)
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??????????????????? WHO Advisory Group
??????????? ?????????????????????
??? Fitness ????????????????
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?????? ?????????????????????????????
???? ??????????????????????????
??????? ?????????? ??? ??? ????? ??????
????? ???????????????
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???????????????????? (Goals of Nursing) 1.
???????????????????????? ??????????? 2.
???????? ?????????? ?????????????????????? 3.
???????/???? ?????????????????????????? 4.
????????????????????????????????????
??????????????
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??? ? 74?? cc ????????? ??? ?? 2 ???

• HXNo underlying disease
• 12 ?? -IOLleft endophthamitis
  
• 19-23??-Cefazolin1 x4, Gentamicin 200 X1
• BUN/CR106/11
• 27-29?? -APD Infected APD
  
  
• -HDInfected Lumen catheter Sepsis x2
• 30?? Ceftriazone 1 x 1 Pancytopenia

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??? ? 70?? CC ????????????? ???????????? 2??

• CASE AS S/P AVR 2536
• ON -COUMADIN 2.5mg/d INR 1?????????1.5
  
• ??? ER INR gt8 -Vit K1 10 mg v FFP 3 UNIT
  
• -Dysnea ,Cyanosis
  
• Intubation on Respirator
  

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???????????????????????????????? (Comprehensive
Geriatric Assessment, CGA) ?????
?????????????????????? -
???????????????????????????? ??? ???
?????
????????????????????????????????????? -
????? ??????????????? ???????
??????????????????????????
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??????????????????? CGA 1. ?????????????????????
- ??????, Response manifestation
????????????????? - ??????? Functional Status
???? 2. Inter related problem 3.
??????????????????????????????????????????????
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????????????????????????????? 1.
????????????????? ????????? ???????????
?????????????? 2. ?????????????????
?????????????, ?????, ???????? over
???? under diagnosisunder/overtreatment 3.
????????????????? Pneumonia 57 ????????
AMI 50 ????? Chest pain
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4. ???????? ??????????? 1 ???/?????????? 5.
???????? ???? Adverse Drug Reaction Drug
Drug Interaction 6. ????????????????????? ?????
Under report 7. ??????????? ?????????????? 8.
??????? Functional Status ???? ????
Iatrogenesis
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?????????????????????????????????? 1. ???????
Sub Acute care 2. ???????long term
carehome care,institutional care with nursing
and social service 3.
??????????????????????? Terminal ill 4.
???????????????????????????????????????.?.???
5. ????????????????/????????
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????????????????????????????????????
Ageism ??????????????????/???????????????
???????????????
??????????????????
Stereotype ???????
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??????????? 1. ????????????????????????
??????????????????? (Decline) 2. Restore or
Rehabilitation ???? 3. ??????????????????????????
??????????????????????? 4. ???????????????????? 5
. ???????????????????????????????????
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?????????? CGA 1. ??????????
?????????????????????????, ??????????
????????????? ?????????????????????????????
2. ??????????????????????????? 3.
??????????????????
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4. ??????????????????????? ??????????
?????????? CGA ????? . ?????????????????????????
???????? . ?????????????????????????????????? .
???????????????????????????????? .
????????????
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?????????? CGA ?? setting ???? ? 1. ????????
?????? ?????????????????????????? 2.
???????Disability Strength?? Rehab
unit 3. ??????? ???????????????????? Long Term
Care 4. ????? Case (Case finding)
Community based Screening
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• ????????????? CGA
• ????????????????????? (Physical assessment)
• 2. ????????????????? ????????( Psychological
  ass)
• 3. ??? ??????????????????? (Social functioning)
• 4. ?????????????????????????? (Functional
  status)

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• ?????????????????????
• 1.2 Medical problem ???????????????????
• ?????????????? ?????????????? ????????????
• 1.3 Health service utilization
• ?????????????????????? ???????????
• ???? OPD ???????????

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• ????????????????????? (Physical Assess)
• 1.3 Health promotion Prevention
• ???????????????????? Exercise Vaccine
• 1.4 Special problem
• - ??, ????? ?????????
• - Nutrition,
• - Vision/Hearing Loss
• - Insomnia

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Vital signs are really vital

• Resp rate Increase are reliable sign of
  infection and/or CHF (gt 26/min)
• Temp unreliable, sub-normal temp (96-97),
  Febrile Serious infection
• Pulse count for 1 full minute both arms
  dysrhythmia with age
• B.P. Check both supine and upright assess
  postural hypotension
• (Hogstel,1994)

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• Timed get-up-and-go test
• sit, stand from arm-chair, walk 3 meters,
  turn, walk back to chair and sit down
• one trial run before timed test
• Categorical scale scoring
• lt 10 sec. freely mobile
• lt 20 sec. mostly independent
• 20-29 sec. variable mobility
• gt 29 sec. impaired mobility

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BALANCE AND GAIT 1.WALK IN STRAIGHT-TURN
180 STAND FOR 2-3 SEC CAN STAND WHEN PUSH
LIGHTLY?
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BALANCE AND GAIT 2.SIT IN AN ARMLESS CHAIR GET
UP WITHOUT USING HAND WALK TURN AROUND WALK BACK
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Risks screening/Geriatric syndrome S Skin
Impairment P Poor Nutrition I
Incontinence C Cognitive Impairment
Delirium (Acute Confusional State)
?????????? E Evidence of Falls
(???????????????) Functional Decline (
?????????????????????) S Sleep Disturbance
???????????????
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Risks screening/Geriatric syndrome 4 IS -
Intellectual (cognitive Impaired) -
Instability (Falls ??? Gait disorder) -
Immobility - Incontinence
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• Iatrogenesis
• Illness from diagnostic treatment procedure
  drug
• Any harmful that is not from patients
  underlying illness
• 50 ????????????? gt60 ?? ?? gt 1 Iatro ??? 36
  ??????????
• (Gurwitz, et al. 1994)

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2.?????????????? ???????? ( Psychological
assessment)
Cognitive MMSE (Mini mental state
examination) gt 26/30 - ok
SPMSQ (Short portable mental
status questionnaire)
??? 0 - 2 error
3 4 mild 5 7
mod 8 - 10 severe
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Cognitive Assessment 1. ?????? (Thinking) 2.
?????? (Remembering) 3. ?????????
(Percieving) 4. ?????????? (Communicating
/orienting) 5. ???????? (Calculating) 6.
??????????? (Problem solving) ????????????????
?? (Reminisence)
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Psychological health (cont.)
Affective Beck Depression Scale
Geriatric Depression Scale
(GDS) 30 ???
??? 0 ??? Depress
gt 10 Depress
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??????? ????????

• 1. ??????????? S/O
• 2. ?????????????????????? S/O
• 3. ?.? ??/???????????????gt 5/?????
• 4. ??????????/?????????????
• 5. ?????????/?????????????????

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??????? ????????

• 6 . ?????????????????
• 7 . ??????????????/???????????????????
• 8. ????? ????/?????????????????s/o
• 9 .????????????? ??????? /???????????????
• ????????? 5/9??????????????????? 1 ????2 ????
  
• ????

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3.??????????????????? (Social Assessment) -
????????????????? (Social network) -
??????????????????? (Social support) -
???????? ????????????????
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??????????????????? ????????

• 1. ???????? ????? ?????????????????? ??
  ?????
• 2 . ??????????????????
• 3 . ???????????????????????????
• 4 . ??????????????????????????
• 5 .

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• ??????????????????????????????????
• (Functional Assessement)
• ?????????????????????????????????????
• ?????????????????????????? ??????????
• ???????????????????????????????????
• ?????????????

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• Functional Assessment
• Basic self care ADL
• ?????????????????????????????
• ????????? ??????? ??????????????

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• 2. More Complex Activities
• Instrumental ADL ???????????????????????
• ????? ????????????????????????????
• ?????????????? ??????? ???????
• ??????? ??????? ??????? ?????
• More Advanced Function
• ???????? ??????????? ???????

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??????????????????????????????? 1.
???????????????????????????????? 2.
??????????????????????? ?????? ?????????
??????????? 3. ?????????????????????
???????? 4. ????????????????????????????????????
????? ????
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5. ??????????????????????? ???????? 6.
??????????????????? 7. ??????????????????????????
??????????? ? 8. ????????????????????????????????
??????? 9. ??????????????????
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???????????????????? ????????????????
???????????? ????????? 1. ?????? 2.
?????? 3. ??????????? 4. ???????????????????
? 5. ???????????????????? 6. ???????????
??????????????????????????
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• ????????????????????
• Co ordinate ??????????????? 1 ?????
• ???????????? ???????????
• Anticipate ??????????????????? Typical
• ???? Geriatric syndrome ?????????
• ??????
• 3. Manipulate ??????????????????
• ????????????????????????????????? ???????

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4. Demonstrate ??????????????????????? 5.
Validate ?????????????????? 6.
Repeat ??????????
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???? ?????? ???????????????????????????????
??????????????? ??????????
?????????? ???????????????? ???????????
???????????????????????????????