Care Of The Older Client (NCM 114a) PDF

Instructional Material for Online Teaching and Learning Care of the Older Client (NCM 114a) Department of Nursing BSN Level III, 2020 1 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  CHA...

Instructional Material for Online Teaching and Learning Care of the Older Client (NCM 114a) Department of Nursing BSN Level III, 2020 1 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  CHAPTER 4: CORE ELEMENTS OF EVIDENCE-BASED GERONTOLOGICAL NURSING PRACTICE Clinical decision making that is grounded in the best available evidence is essential to promote patient safety and quality health care outcomes. With the knowledge base for geriatric nursing rapidly expanding, assessing geriatric clinical practice guidelines for their validity and incorporation of the best available evidence is critical to the safety and outcomes of care. Evidence-based practice (EBP) is a framework for clinical practice that integrates the best available scientific evidence with the expertise of the clinician and with patients’ preferences and values to make decisions about health care (Boltz, M. et al, 2016). The role of the gerontological nurse is influenced by a number of factors (e.g., legal dimensions, legislative authority, human rights, current social and political trends, growth of specialization and professional organizations that require inter-sectoral collaborations). Gerontological nurses work in a variety of roles and in their practice apply theoretical knowledge of aging across the continuum of aging, and promote wellness to enhance quality of life in chronic illness. This chapter is divided into two (2) lessons. Overall, this chapter will consume four (8) hours for lecture. Lesson 1: Standards, Competencies, and Principles of Gerontological Nursing Practice Lesson 2: Issues and Concerns on Gerontological Nursing Practice  Ethico-Legal Considerations in the Care of Older Adult  Communicating with Older Persons  Guidelines for Effective Documentation  Geriatric Health Care Team LESSON 1: STANDARDS, COMPETENCIES AND PRINCIPLES OF GERONTOLOGICAL NURSING PRACTICE Practice standards describe the appropriate therapeutic health and wellbeing of gerontological nurses to facilitate the older person’s health, recovery and/or wellbeing and comfort. “The primary purpose of having standards is to provide direction for professional practice in order to promote competent, safe and ethical service for clients”. After completing this lesson, you must have: 1. Enumerated the purpose of standards of gerontological nursing practice. 2. Applied the standards, competencies and principles in the care of older client. 2 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114 Warm-up Activity: Answer the following questions: 1. Have you ever cared for an elderly person before? If so, what was that experience like? 2. How do you feel about caring for older adults in your nursing practice? Learning Inputs: A. Standards of Gerontological Nursing Practice The standards for clinical gerontological nursing include assessment, diagnosis, outcome identification, planning, implementation, and evaluation (ANA, 2001). The standards of professional gerontological nursing performance include quality of care, performance appraisals, education, collegiality, ethics, collaboration, research, and research utilization. Purpose of Standards of Practice  Define the scope and depth of gerontological nursing practice  Establish criteria and expectations for high quality nursing practice and safe, ethical care  Provide criteria for measuring actual and desired performance  Support ongoing development of gerontological nursing  Promote gerontological nursing as a specialty, providing the foundation for certification of gerontological nursing by the Canadian Nurses Association  Promote components of gerontological nursing knowledge as entry-to-practice competencies, setting a benchmark for new graduates  Inspire excellence in and commitment to gerontological nursing practice Standards of Gerontological Nursing Practice (Adapated from Canadian Gerontological Nursing Association (2019). Gerontological Nursing Standards of Practice and Competencies 2019 (4th ed.). Toronto, Canada: CGNA) STANDARD I: HUMANISTIC AND RELATIONAL CARE Definition: Gerontological nurses develop and preserve relationship care. Gerontological nurses understand that reciprocal communication and respectful interactions are central to the central human enterprise of nursing (Sakamoto, et al., 2017). Relationship-centered care is the foundation of a humanistic approach to provide high-quality care for older people and their care partners and is dependent upon empathy and understanding. 3 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  Gerontological Nurses address:  Humanistic nurse, older person and care partner relationships to optimize health and wellbeing of older people and their care partners  Personal, older person and care partner preferences, reflecting one’s unique experiences, cultural context, and social determinants of health.  Relational care approaches to value the person-centred and ethical issues that affect person-centred care  Gerontological nurses recognize their role as part of an inter-professional collaboration STANDARD II: ETHICAL CARE Definition: Gerontological nurses understand the importance of the ethical underpinnings of nursing. Gerontological nurses are consciously aware of and think critically about what ought to happen, what should be done and what is fair and just. Gerontological nurses are respectful of the person’s right to self-determination, choice and collaborative decision-making. Gerontological nurses recognize that the ethical care of older people and their care partners will involve clarification of conflicting values and exploring alternatives. Gerontological nurses understand that ethical principles and codes form the basis upon which ethical decisions and actions rest. In particular, Gerontological nurses adhere to the Code of Ethics. Gerontological Nurses address:  Older people and care partners as advocates  Human right for autonomy, diversity, inclusion  Self-determination and freedom of expression  Ethical, moral and legal contexts of nursing practice  Collaborative decision-making (e.g. beginning and ending treatments, end-of-life care, medical assistance in dying)  Access to and provision of care reflecting the person’s preferences and cultural requirements  Promotion and support of autonomy and independence STANDARD III: EVIDENCE-INFORMED CARE Definition: Gerontological nurses recognize that nursing care for older people and their care partners is based on evidence-informed knowledge, which is comprehensive and complex. Gerontological nurses have inquiring minds, question the status quo, and seek new evidence-informed knowledge to answer questions when faced with nursing care challenges. Gerontological nurses provide comprehensive assessment and treatment of older people needs using standardized 4 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  assessments, including reliable and valid measures and evidence-informed interventions. Gerontological nurses actively engage in knowledge to action translation aiming to achieve promotion and optimization of older person’s well-being, regardless of presence of acute/chronic illness or end-of-life care needs. Gerontological Nurses address:  All aspects of health and well-being  Information and educational needs  Assessment of health, functional and cognitive capacities  Geriatric syndromes  Pain and symptom management  Acute illness and chronic health conditions management  Medication management,  Behavior and cognitive therapy  Adaptive communication needs  Advance care planning  Coping and grieving  End-of-life care (EoLC) and Medical Assistance in Dying (MAiD) STANDARD IV: AESTHETIC/ARTFUL CARE Definition: Gerontological nurses recognize that nursing care of older people and their care partners must reflect aesthetic practices, the art of nursing. Gerontological nurses recognize the importance of searching for the deeper meaning of the older person’s health/illness/dying experience. Consequently, gerontological nurses seek to connect to the human experience of sickness, suffering, recovery, transitioning and death through provision of care that is artful, person-centred, and grounded in evidence-informed, ecopsychosocial practices. Gerontological nurses understand that environmental strategies are effective in supporting the delivery of person-centered care and can have a strong potential in making positive impact on aging experiences. Gerontological nurses understand that the ‘experience’ of care is highly influenced by the social and physical environment within which care is delivered. Therefore, gerontological nurses are sophisticated in their ability to interact with older people and their care partners to create a holistic environment that is pleasing, comforting and supportive. In addition, gerontological nurses ensure that older people and their care partners have access to evidence-informed aesthetic practices (music, poetry, stories, drawings, etc.) that promote interpersonal strength, coping and resilience. Gerontological Nurses address:  Need for older people to share experiences and their meaning 5 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114   Aesthetics of living/caring spaces (e.g. acute, convalescent and long-term care spaces, bedrooms, common rooms, bathrooms, bathing environments and mealtime environments)  Environmental design (wall colour, pictures, plants, photographs, drawings, where appropriate)  Need for music, warmth, comfort, food, artistic elements, presence of familiar people or objects  Access to activities that spring from need for creative expression through interpersonal health resources such as mindfulness, yoga, dance, massage, movement, art therapy, interaction with living organisms such as plants, animals, pets, nature  Appropriate skill mix, shared decision-making, shared power, effective staff relationships and supportive organizational systems STANDARD V: SAFE CARE Definition: Gerontological nurses are responsible for assessing the older person and the environment for hazards that threaten safety, as well as planning and intervening appropriately to maintain a safe environment. Gerontological nurses collaborate with the older person and care partners in acknowledgement of their right to live at risk and need for autonomy. Gerontological Nurses address:  Health literacy (e.g. accessible access to accurate, relevant and safe health information resources, including technology)  Culturally competent and safe care  Equipment requirements for maintaining safety (e.g. transfers, mobility, stairs)  Risk reduction and monitoring of risk over time Assessment, prevention and mitigation of all forms of abuse  Safe interpersonal relationships, including relationships of intimacy  Assessment of risk; reduction, mitigation, and monitoring of risk over time (e.g. falls, depression, disaster planning, suicide, self-harm, self-neglect, access to required medication, review of medication or substances abuse or misuse, polypharmacy, STIs)  Food security  Access to safe and affordable housing STANDARD VI: SOCIO-POLITICALLY ENGAGED CARE Definition: Gerontological nurses are aware of the socio-economic-political contexts that influence all aspects of care. As such, Gerontological nurses collaborate with older people and their care partners to advocate for equitable access to health system resources that address their care needs. Gerontological nurses provide 6 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  systems to support and sustain practice changes, including ongoing social justice advocacy, education, policies and procedures and job descriptions. Gerontological Nurses address:  Ageism that limits health care delivery and stigmatizes older people within society  Care inequities across all sectors of health care delivery  Inadequate health policy at the local, provincial and national levels  Advocacy needs of the older person within the healthcare system B. Gerontological Nursing Competencies 1. Incorporate professional attitudes, values, and expectations about physical and mental aging in the provision of patient-centered care for older adults and their families. 2. Assess barriers for older adults in receiving, understanding, and giving of information. 3. Use valid and reliable assessment tools to guide nursing practice for older adults. 4. Assess the living environment as it relates to functional, physical, cognitive, psychological, and social needs of older adults. 5. Intervene to assist older adults and their support network to achieve personal goals, based on the analysis of the living environment and availability of community resources. 6. Identify actual or potential mistreatment (physical, mental, or financial abuse, and/or self-neglect) in older adults and refer appropriately. 7. Implement strategies and use online guidelines to prevent and/or identify and manage geriatric syndromes. 8. Recognize and respect the variations of care, the increased complexity, and the increased use of healthcare resources inherent in caring for older adults. 9. Recognize the complex interaction of acute and chronic comorbid physical and mental conditions and associated treatments common to older adults. 10. Compare models of care that promote safe, quality physical and mental health care for older adults such as PACE, NICHE, Guided Care, Culture Change, and Transitional Care Models. 11. Facilitate ethical, noncoercive decision making by older adults and/or families/caregivers for maintaining everyday living, receiving treatment, initiating advance directives, and implementing end-of-life care. 12. Promote adherence to the EBP of providing restraint-free care both physical and chemical restraints). 13. Integrate leadership and communication techniques that foster discussion and reflection on the extent to which diversity among nurses, nurse assistive 7 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  personnel, therapists, physicians, and patients has the potential to impact the care of older adults. 14. Facilitate safe and effective transitions across levels of care, including acute, community-based, and long-term care le g., home, assisted living, hospice, nursing homes for older adults and their families. 15. Plan patient-centered care with consideration for mental and physical health and well-being of informal and formal caregivers of older adults. 16. Advocate for timely and appropriate palliative and hospice care for older adults with physical and cognitive impairments. 17. Implement and monitor strategies to prevent risk and promote quality and safety e.g., falls, medication mismanagement, pressure ulcers) in the nursing care of older adults with physical and cognitive needs. 18. Utilize resources/programs to promote functional, physical, and mental wellness in older adults. 19. Integrate relevant theories and concepts included in a liberal education into the delivery of patient- centered care for older adults. C. Principles of Gerontological Nursing 1. Aging is a natural process. 2. Various factors influence the aging process. 3. Nursing of the elderly requires unique information and skills. 4. There are common needs shared by the elderly and all age. 5. Gerontological Nursing’s goal is to promote optimum levels ofphysical, psychological, social and spiritual health. Activity 1.Look at the list of competencies for gerontological nurses. How many of these competencies do you feel you meet at this point? Make a conscious effort to develop these skills as you go through your career. Wrap-up Activity In conclusion, our attitudes about aging and caring for the elderly are influenced by many factors. Because of the changing population, all nurses need to have basic competence in the care of older adults. Gerontological nursing practice is guided by standards and core competencies. The scope of practice may be expanded with formal advanced education, and certification at any level is a way to demonstrate expertise. Post-assessment: A quiz will be uploaded in the mVLE after the discussion. References: 8 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  Boltz, M., Capezuti, L., Fulmer, T. T., & Zwicker, D. (2016). Evidence-based geriatric nursing protocols for best practice. 5th edition. New York, NY: Springer Publishing Company, LLC. Canadian Gerontological Nursing Association (2019). Gerontological Nursing Standards of Practice and Competencies 2019 (4th ed.). Toronto, Canada: CGNA Mauk, K. L. (2014). Gerontological Nursing: Competencies for Care (3rd edition). Burlington, MA: Jones & Bartlett. LESSON 2: ISSUES AND CONCERNS ON GERONTOLOGICAL NURSING PRACTICE The health of older client is a critical issue during this century. The health care providers may have to rethink fundamental cultural values about the meaning of providing health care to older adults with chronic conditions. Simply treating disease is no longer sufficient. The growing number of older adults, and the families who care for them, will need emotional, educational, and financial resources that are not currently available. This growing elderly population will have an increasing need for health care and related services, an effect that will ripple through society as we grapple with the implications of caring for our elders. The increased proportion of older adults in the population need not present major problems if we can provide appropriate resources for adequate quality of life for older adults, such as specialized health care that includes attention to the management of chronic illness, support for family caregivers, and the financial constraints of older adults. After completing this lesson, you must have: 1. Identified the different laws affecting older clients/ senior citizens. 2. Identified the privileges of older clients/ senior citizens in the acquire healthcare services. 3. Discuss demographics related to aging and medication use. 4. Explain age-related pharmacokinetic changes. 5. Determined what is the effect of polypharmacy to older clients. 6. Review the nurse’s role in the older adult’s adherence to a medication regimen. 7. Critically evaluated selected case studies related to older adults and medication. 8. Define key ethical constructs as they relate to the care of geriatric patients. 9. Discuss concepts of ethics and the implications in the care of geriatric patients. 10. Identified attitudes towards death and dying. 11. Recognized the choices of the elderly and their families in directing their end-of-life care as well as the nurse’s role in support/implementation of the patient’s choice. 12. Recognized the important of spirituality in older clients. 13. Discussed the nurse’s role at end of life using the above concepts of care. 14. Communicated effectively, respectfully, and compassionately with older adults and their families. 15. Identified physiological and psychosocial barriers to communication among older adults. 16. Recognized the nurse’s role and responsibility in the process of communication. 17. Utilized basic principles when communicating with older adults. 9 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  18. Identified and used strategies to overcome communication barriers. 19. Described the reasons for accurate and thorough documentation in gerontological nursing. 20. Compare the major documentation methods used in acute, long-term, and home care. 21. Appreciate the unique contributions that the interdisciplinary geriatric team can make towards helping older adults achieve their maximal levels of independence. Warm-up Activity: Before you proceed to learning inputs, 1. What are the age-related changes that occur in pharmacokinetics of the older adults? 2. As you prepare to care for older adults, what values, conflicts, or ethical dilemmas do you anticipate you will face? 3. Explain the reasons why documentation is critical to patient care. Learning inputs: A. Ethico-Legal Considerations in the Care of Older Adult Ethics is a fundamental part of geriatrics. Ethics, or the provision of ethical care, refers to a framework or guideline for determining what is morally good or bad. Ethical problems arise when there is conflict about what is the “right” thing to do. This dilemma generally occurs when decisions need to be made whether or not a medical intervention should be implemented and whether or not the intervention is futile. The answers to ethical questions are not straightforward; they involve a complex integration of thoughts, feelings, beliefs, and evidence-based data. Ageism can play a strong role in these decisions. Acknowledging and acting on the wishes of the older individual are a critical component of ethical care (Kane, 2013). 1. Laws Affecting Senior Citizens/Older Persons a. Republic Act 7432 - An act to maximize the contribution of senior citizens to nation building, grant benefits and special privileges and for other purposes. b. Republic Act 9257 - Expanded Senior Citizens Act of 2003. - An act granting additional benefits and privileges to senior citizens amending for the purpose Republic Act 7432. c. Republic Act 9994 - Expanded Senior Citizens Act of 2010. - An act granting additional benefits and privileges to senior citizens amending for the purpose Republic Act 9257. 10 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  - RA 7432 RA 9257 RA 9994 Exemption from ITR Exemption from ITR a. Exemption from Income Tax who are considered to be minimum - Annual TaxabIe does - Annual TaxabIe does not exceed the wage earners under RA 9504. not exceed P60k or such poverty level as determined by NEDA amount determined by b. 20% discount and exemption from VAT: NEDA 20% discount from all establishments on 1. Purchase of medicines, influenza and pnuemococcal vaccines, services of hotels and similar lodging and other essential medical supplies, accessories and 20% discount on establishments, purchase of medicines for the equipments transportation services, exclusive use and enjoyment of SC, and 2. PF of attending physicians hotels and similar lodging funeral and burial services 3. PF of licensed professional health providing home health care establishments, services restaurant, recreation 20% discount on admission fees on theaters, 4. On medical/dental services, diagnostic and laboratory fees centers, and purchases of cinema houses, concert halls, circuses, 5. In actual fare for land transportation travel in PUBs, PUJs, medicine anywhere in the carnivals etc. taxis,AUVs, shuttle services and public railways, including LRT, country MRT, and PNR 20% discount on medical dental services, PF of 6. Actual transportation fare for domestic air transport services Min. of 20% discount on attending doctors and diagnostic and and sea shipping vessels, based on the actual fare & advanced admission fees on laboratory fees booking theaters etc. 7. On the utilization of services in hotels and similar lodging 20% discount in fare for domestic air and sea establishments, restaurants and recreation centers travel 8. On admission fees charged by theaters, cinema houses and concert halls, circuses, leisure and amusement; and 20% discount in public railways, skyways and 9. On funeral and burial services for the death of senior citizen bus fare c. Grant of a minimum of 5% discount on the monthly utilization of water and electricity supplied by public utilities 11 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  Privileges for Senior Citizens (a) The grant of twenty percent (20%) discount and exemption from the value added tax (VAT) on the sale of the following goods and services: 1. on the purchase of medicines 2. on the professional fees of attending physician/s 3. on the professional fees of licensed professional health providing home health care services 4. on medical and dental services, diagnostic and laboratory fees 5. in actual fare for land transportation travel 6. in actual transportation fare for domestic air transport services and sea shipping vessels and the like 7. on the utilization of services in hotels and similar lodging establishments, restaurants and recreation centers 8. on admission fees charged by theaters, cinema houses and concert halls, leisure and amusement 9. on funeral and burial services for the death of senior citizens (b) exemption from the payment of individual income taxes of senior citizens who are considered to be minimum wage earners in accordance with Republic Act No. 9504 (c) the grant of a minimum of five percent (5%) discount relative to the monthly utilization of water and electricity supplied by the public utilities (d) Exemption from training fees for socioeconomic programs (e) Free medical and dental services diagnostic and laboratory fees in all government facilities (f) Free vaccination against the influenza virus and pneumococcal disease for indigent senior citizen patients (g) Educational assistance to senior citizens (h) The continuance of the same benefits and privileges given by the GSIS, the SSS and the PAG-IBIG as the case maybe, as are enjoyed by those in actual service (i) The retirement benefits of retirees shall be regularly reviewed to ensure their continuing responsiveness and sustainability (j) The government may grant special discounts for senior citizens on purchase of basic commodities (k) Provision of express lanes for senior citizens (l) Death benefit assistance of a minimum of P 2,000.00 12 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  2. Medications of Older Adults (Polypharmacy) Figure 1.Physiological changes of aging and the pharmacokinetics and pharmacodynamics of drug use.Adapted from Touhy, T. A., Jett, K. F., & Ebersole, P. (2014). Ebersole and Hess' gerontological nursing & healthy aging. 4th ed. St. Louis, Mo.: Elsevier/Mosby. Older adults have a high prevalence of multiple chronic health conditions for which multiple medications are typically recommended as treatment. Thus, effective and safe drug therapy is one of the greatest challenges within the elderly population. Consequently, multiple medication use, often referred to as polypharmacy, is common in this population. It is also defined as the prescription, administration, or use of more medications than are clinically indicated in a given patient. Effects of polypharmacy: (a) it may increase the risk of using potentially inappropriate medications which have been associated with negative effects on long-term physical and cognitive functioning (b) results in medication nonadherence (c) increased risk of drug duplication, drug–drug interactions and adverse drug reactions (d) higher health care costs 13 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  The nurse plays a key role in screening for polypharmacy. When determining if a medication is appropriate for a patient, the nurse should ask the following questions: Is the treatment necessary? Is this the safest drug available? Is this the most appropriate dose, route of administration, and dosage form? Is the frequency appropriate? Do the benefits outweigh this risk? Quality Indicators for appropriate Medication Use in Older Adults Indicator Description Rationale Indication When prescribing a new drug, the The medication may have been therapy should have a clearly prescribed for an indication that defined indication documented in was unclear or transient. the medical record. Patient Education When prescribing a new drug, the Education may improve patient or caregiver should be adherence, clinical outcomes, educated about the optimal use and alert patients or caregivers of the therapy and the to potential adverse events. anticipated adverse events. Medication list Medical records (outpatient or Allows identification and hospital) should contain a current elimination of duplicate medication list. therapies, corrects drug interactions, and streamlines the drug regimen to improve adherence. Response to therapy Every new drug prescribed on an Provides a rationale for ongoing basis (e.g., for a chronic continuation of the therapy if condition) should have effective, or change or documentation of response of discontinuation if ineffective. therapy within 6 months. Periodic drug review Annual drug regimen review. Provides an opportunity to discontinue unnecessary therapy or to add needed drug therapies. Monitoring warfarin When warfarin is prescribed, Older adults are at high risk for therapy international normalized ratio drug toxicity that can be (INR) should be evaluated within identified earlier if there is close 4 days and at least every 6 weeks. monitoring for agents with a narrow 14 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  therapeutic range Monitoring diuretic When a thiazide or loop diuretic Risk of hypokalemia because of therapy therapy is prescribed, electrolytes diuretic therapy. should be checked within 1 week after initiation and at least annually. Avoid use of When prescribing an oral This therapy has a prolonged chlorpropamide as a hypoglycemic agent, half-life that can result in serious hypoglycemic chlorpropamide should not be hypoglycemia and is more likely Agent used. than other agents to cause the syndrome of inappropriate secretion of antidiuretic hormone. Avoid drugs with strong Do not prescribe drug therapies These therapies are associated anticholinergic with a strong anticholinergic with adverse events such as Properties effect if alternative therapies are confusion, urinary retention, available. constipation, and hypotension. Avoid barbiturates If older adult does require the These therapies are potent therapy for control of seizures, do central nervous system not use barbiturates. depressants, have a low therapeutic index, are highly addictive, cause drug interactions, and are associated with an increased risk for falls and hip fracture Avoid meperidine as an When analgesia is required, avoid This therapy is associated with an opioid analgesic use of meperidine. increased risk for delirium and may be associated with the development of seizures. Monitor renal function If angiotensin-converting enzyme Monitoring may prevent the and potassium in inhibitor therapy is initiated, development of renal patients potassium and creatinine levels insufficiency and hyperkalemia. prescribed should be monitored with 1 week angiotensin-converting of initiation of therapy. enzyme inhibitors 3. Ethical Principles The ethics of care in the geriatric population, as in others, include compassion, equity, fairness, dignity, confidentiality, and mindfulness of a person’s autonomy within the 15 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  realm of the person’s abilities and mental capacity. It is not possible to care for this population without being faced with difficult choices surrounding issues relating to the ability to live independently. (a) Advocacy - refers to loyalty and a championing of the needs and interests of others requiring the nurse to educate patients and their families so that they know their rights, are fully informed, and are able to access all the benefits they are entitled to (b) Autonomy - is the concept that each person has a right to make independent choices and decisions. It is reflected in guidelines and laws regarding patient rights and self-determination. Concept Related to Autonomy: Elderly patients often have chronic and ultimately fatal illnesses. The care of patients in the severe-to-terminal stages of these illnesses typically involves decisions that require tradeoffs between different kinds of symptoms, or quality versus quantity of life. The patients are often unable to make decisions. One strategy to make these difficult decisions is to make them in advance when the patient is competent. Advance care planning describes competent patients discussing and then documenting their preferences for future medical care. This preserves patients’ self-determination even after they have lost decision-making capacity. The classic mechanism to do this is an advance directive. (1) Advance directive is a set of instructions indicating a competent person’s preferences for future medical care should the person become incompetent or unable to communicate. Advance directives typically focus on the conditions of being terminal, comatose, or in a state of irreversible suffering. However i. Living will  A document describing a patient’s preferences for the initiation, continuation, or discontinuation of particular forms of treatment. ii. Durable power of attorney (DPA)  a.k.a., health care proxy  A document that designates a surrogate (also called an “agent,” “proxy,” or “attorney-in-fact”) to make medical decisions on a person’s behalf should that person become unable to make a decision. 16 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  (c) Beneficence/Nonmaleficence - These concepts of do good (beneficence) and do no harm (nonmaleficence) are integral to healthcare. Nurses intend to do good for their patients.Nurses are also concerned about situations thatcan result in harm to patients (d) Confidentiality - the right to privacy. - requiring that only persons with a need to know access the patient’s record or receive information about the patient. (e) Fidelity - refers to keeping promises or being true to another; being faithful to commitments and responsibilities (f) Fiduciary Responsibility - Health care professionals have an ethical obligation to good stewardship of both the patient’s and the organization’s funds—fiduciary responsibility. This refers to using both fiscal reserves and caregiving resources wisely, potentially requiring a cost-benefit analysis to facilitate decision making. (g) Justice - refers to the fairness of an act or situation. (h) Quality & Sanctity of Life - Quality of life is one’s personal perception of the conditions of life, and sanctity of life, referring to the value of life and the right to live. (i) Reciprocity - is a feature of integrity concerned with the ability to be true to one’s self while respecting and supporting the values and views of another. (j) Veracity - means truthfulness and refers to telling the truth, or, at the very least, not misleading or deceiving patients or their families. 17 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114 Long Term Care, Palliative Care, and End-of life Care Anthropologist Margaret Mead was quoted as saying, “When a person is born we rejoice, and when they’re married we jubilate, but when they die we try to pretend nothing happened.” This part deals with the nurse’s role in assisting a patient and family to identify the options for meeting end-of-life needs. It promotes the role of the nurse as a member of a team of professionals who focus on care and treatment of issues specific to the elderly as their health declines. It also offers practical assistance for nurses as they deal with various aspects of, end-of-life care. (a) Long-term care - refers to myriad services designed to provide assistance over prolonged periods to compensate for loss of function due to chronic illness or physical or mental disability. - varies in frequency and intensity according to the needs of the recipients, and it includes both hands-on, direct care as well as general supervisory assistance. - LTC is distinct from acute or episodic medical interventions because care must be integrated into an individual’s daily life over an extended time period. - supports older adults in two distinct realms: o Activities of daily living (ADLs). ADLs include such basic functions as eating, bathing, dressing, getting into and out of bed or a chair, and using the toilet. o Instrumental activities of daily living (IADLs). IADLs are additional tasks necessary to maintain independence, such as preparing meals, managing medications, shopping for groceries, and using transportation. (b) Palliative Care - Palliative care is interdisciplinary care focused on the relief of suffering and achieving the best possible quality of life for patients and their loved ones. - It is offered simultaneously with life-prolonging and curative therapies for persons living with serious, complex, and eventually terminal illness.  involves formal symptom assessment and treatment, aid with decision making and establishing goals of care  practical support for patients and their caregivers, mobilization of community support and resources to ensure secure and safe living environments  collaborative and seamless models of care (hospital, home, nursing homes, and hospice).  focuses on comfort rather than cure  focuses on the treatment of symptoms rather than disease  focuses on quality of life left rather than quantity of life lived. 18 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  (c) End-of life Care - The focus of care at end of life should center on living with terminal illness—with medical care, support, and interventions geared toward quality of life and comfort, rather than on prolonging suffering or the dying process—if that is what patient wants. The EoLC has become a new phenomenon encompassing all aspects of care at the end of individuals life. It is now a preferred term when identifying a person who is in the final stages of life which may last years, months, weeks or days. 12 principles: 1. Pairing profile on death and dying 2. Strategically commissioning services to provide the best quality care 3. Identifying people approaching end of life 4. Care planning 5. Coordination of care 6. Rapid access to care 7. Delivery of high quality services in all locations 8. Last day of life and care after death 9. Involving and supporting for care 10. Education and training and continuity professional development 11. Measurement and research 12. Funding to support the principles The End-of-Life Strategy 1. Step 1 – Discussion as the end of life approaches  Good communication skills is essential Four aspects of awareness may influence discussion between nurse and patient (Glaser & Strauss, 1965 in Kozier, 2015) i. Closed awareness ii. Suspicion iii. Mutual preference iv. Open awareness 19 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  Factors to consider Guidelines The environment Privacy, no interruptions Body language Understand how posture/body language may reflect barriers in communication Non-verbal communication Personal space, posture, gesture Verbal communication Use of simple language and open-ended questions Listening Use of silence, body language, what is being said Demonstrating empathy Acknowledge feelings Reflection Assess level of understanding and document/share with MDT Barriers Address 2. Step 2 – Assessment, care planning, and review  A holistic common assessment is essential o Patient-centered o Continuous process The most important aspect of the holistic assessment is verifying levels of understanding of the diagnosis, treatment options, and prognosis Five Domains of Assessment: These form an essential part of the Gold Standard Framework i. Background information and assessment preferences ii. physical needs iii. social and occupational needs iv. Physical well-being v. spiritual well being and life goals The Gold Standard Framework  is a system-focused approach formalizing best practice for individuals in their last year of life.  It provide tools and resources that can be used by professionals to identify, assess and plan care in more coordinated and communicated way. - The GSF is a tool that empowers the family of the dying patient to provide the best care possible. 20 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  - Based from the GSF, patients are identified based on this premise that they have at most 6 months to live - Patient-centered – term describing that assessment should encompass all aspects of a person. Key aspect of Gold Standard Framework – enable the MDT to plan ahead, anticipate possible crises, assess carers’ needs and manage bereavement concerns of the family. The GSF comprises: One aim – to deliver a “gold” standard of care for all patients nearing the end of life Three steps: identify, assess, plan a) Identify- the last year of life (6-12 months) and list those identified patients for the MDT to proactively plan care. The care plan is based on the stage of the disease that is predicted using the needs Based Coding:  All from diagnosis; stable; years plus prognosis  benefits; unstable/advanced disease; months prognosis  continuous care; deterioration; needs prognosis  days/final days; terminal care; days prognosis “After Care” b) Assess – through holistic common assessment  Assess needs for anticipatory care  Assess for carers’ needs  Assess if patient is entitled to some benefits c) Plan – general care generated from assessment, ACP discussions and any recorded wishes/choices Five goals:  consistent high quality care  alignment with patient’s preferences  pre-planning and anticipation of needs  improved staff confidence and teamwork 21 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114   more home-based, less hospital-based care 3. Step 3. Coordination of Care  It should be ensured that MDT is communicating and coordinating care.  Communication links with out-of-hours services and/or night community nursing services. 4. Step 4. Delivery of high quality services  High-Quality Care provisions in all settings  Available transportation services – eg. Ambulance 5. Step 5. Care in the last days of life  Identify the dying phase o There is gradual or rapid shutting down of body processes, biographic disengagement and closure and relinguishment of everyday life interests and activities. o Review needs, preferences for place of death, wishes for organ donation, resuscitation, etc. Liverpool Care Pathway - The LCP is a tool encompassing assessment and care plan for patients identified as dying Key features of the LCP” 1. Symptom control - eg anticipatory prescribing of medicine 2. Comfort measures – eg. Provision of psychological and spiritual care 3. Discontinuation of inappropriate measures – eg. Blood tests, resuscitation status 4. Communication and coordination – informing the MDT especially OOH 5. Care of the family – check understanding, care before and after death. 6. Step 6. Care after Death  MDT should recognize that EoLC does not stop at the point of death  Care and support to family member  Provide an aide – based on the policy of the institute or local. 22 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  5.Spirituality Among Older Persons Spirituality - the personal quest for understanding answers to ultimate questions about life, about meaning, and about relationships that are sacred or transcendent (Koenig, McCullogh, and Larson , 2001) It is of great importance that nurses understand that spirituality and the practice of religion vary greatly among older adults. While the process of aging often fosters a search for the meaning of life, not all older adults search in the same way. The nurse is likely to practice a religion different from the older adult, so it is important that the nurse does not impose their personal beliefs and religious views on their patients. The nurse must be open and understanding, allowing the older adult to pursue spirituality in their own unique way. In conducting spiritual assessments, the nurse may ask about many topics: (1) the individual’s beliefs and practices; (2) what spirituality means to the client; (3) whether the client is affiliated with specific religions and is actively involved; (4) whether spirituality is a source of support and strength; and (5) whether the client has any special religious traditions, rituals, or practices they like to follow. Nursing Interventions: (1) nurse should encourage religious and spiritual beliefs and practices in all environments of care, as allowed by institutional policy (2) It is important for the nurse to be aware of the availability of religious personnel within each facility and call upon these members of the interdisciplinary team to help the older adult whenever necessary. (3) Spiritual counseling and praying with the patient are often great sources of comfort to the patient and family. B. Communicating with Older Persons Caring for geriatric patients also require professional competence and specific communication skills. A considerable part of them have the need of more attention and time to digest an information. Absorption and application of communication skills with an adult are a significant factor for understanding and proper evaluation of his condition. “There may be no single thing more important in our efforts to achieve meaningfulwork and fulfilling relationships than to learn to practice the art of communication.” —Max DePree 23 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  1. Information Sharing Elderly patients often share control of their personal health information and decision making with family and friends when needed. Patient portals can help with information sharing, but concerns about privacy and autonomy of elderly patients remain. While elders may delegate control and share information with family, they want to retain granular control of their information. Consequences on information sharing: (1) elders and caregivers have different perspectives on what is seen as the "burden" of information (2) access to medical information by families can have unintended consequences, and (3) elders do not want to feel "spied on" by family. Second, control of information sharing is dynamic (4) elders wish to retain control of decision making as long as possible (5) transfer of control occurs gradually depending on elders' health and functional status (6) control of information sharing and decision making should be fluid to maximize elders' autonomy (7) no "one-size-fits-all" approach can satisfy individuals' different preferences. Information sharing and control are complex issues even under the most well-meaning circumstances. 2. Non-verbal Communication - refers to behaviors or gestures that convey a message without the use of verbal language. (a) Vocal nonverbal communication refers to the tone, pitch, speech rate, or fluency of verbal communication. (b) Nonvocal nonverbal communication refers to the use of facial gestures, body posture, eye contact, and touch as a means of communication. 3. Communicating with Older Adults In her book, Making Contact, renowned family therapist and author Virginia Satir describes the basic principles for making contact and communicating with others. The basic principles are invite, arrange environment, maximize communication, maximize understanding and follow through. (1) Invite - An invitation says to the other person that you are interested in them and sharing time with them. 24 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  Strategy: a) Health care providers can make a number of gestures that show respect and interest in the patient as a person. b) greet the person by name and ask a nonthreatening open-ended question, thereby engaging the person in conversation. (2) Arrange the environment - environment should be comfortable, provide privacy, and minimize distractions that could be barriers to communication, such as noise or poor lighting. (3) Maximize communication - use communication strategies that maximize the individual’s ability to understand the message. This includes using language and terminology that are familiar to the patient. - Periodically ask the receiver to clarify what he or she is hearing as a means of ensuring accurate interpretation of your message. (4) Maximize understanding - We must be open minded and provide opportunities for the individual to share their thoughts with us. It means allowing time to communicate and focusing attention on the person at the time of the conversation. (5) Follow up and follow through - Words backed by actions help develop trust. A relationship built on trust and concern for the welfare of others is critical to optimal health outcomes. 4. Barriers to Communication Many factors can lead to breakdowns in communication. Be aware of the following age-related issues:  hearing impairment;  declining sight or vision;  declining memory and,  inability to read or understand. Other issues include:  the type of information being shared,  understanding of an issue or topic,  the environment, and  personal style, such as use of body language, tone of voice, choice of words, speaking pace and more. 5. Skills and Techniques 25 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  SAGE ADVICE (Adapted from Look Close See Me, Aging & Communications: Engaging Older People. 2011. University of Cincinnati College of Nursing) S is for SIMPLIFY. Instead of technical or medical terms, use simple words that older people are likely to be familiar with and understand. A is for ASSURE. Don’t assume all older people are deaf, dumb or blind. Assure them they matter by communicating with kindness and involving them in the conversation. G is for GIVE information. Help older people make informed decisions by sharing information in the way they prefer. Writing or demonstrating something can be helpful. E is for EASE into it. Avoid sharing too much, too quick. Unfamiliar situations can be overwhelming, so slow down and allow people time to process the information. A is for ACKNOWLEDGE. Instead of overlooking older people, recognize, engage and listen to them. D is for DISCOVERY. Just because someone nods their head doesn’t mean they understand you. Ask older people questions to see if they truly comprehend. V is for VALUE. Avoid using overly friendly terms and baby talk. Instead, respect older people by using their proper name such as Mr. Smith. I is for INDIVIDUALIZE. Acknowledge language barriers and be sensitive to one’s values, cultural beliefs and changes associated with natural aging. C is for COMMUNICATE. Avoid telling people what to do. Instead, focus on what is most important for them to know and consider. Make sure they understand what is required of them. E is for EMPATHIZE: Try to understand a situation from the older person’s perspective. Watch for feedback and cues to guide communication and information sharing. Be sensitive to the situation, potential challenges and needs. KEY POINTS TO REMEMBER Consider the following as you interact with older people: 1. Older people need and are entitled to be recognized when matters involve them. Even if a person has dementia or memory loss, direct your comments and attention to him or her. 2. You can interact more effectively by understanding how aging changes can impact communication. 3. We must communicate respectfully with older people and provide the right information the right way to help them make informed decisions. Communicating with Individuals with Memory or Cognitive Deficits Invite, Respect  Approach persons in a nonthreatening manner within their visual field.  Sit quietly with the person and gently touch her hand.  Be respectful of the patient’s belongings. At times patients can get 26 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  overly upset when an outsider touches their belongings, even basic items such as the tissue box or washcloth. Ask permission before moving objects.  Show concern; stop and have a conversation—don’t limit communication to times when you need information. Environment  Post a few pictures, a calendar, or a daily schedule in the patient’s room and use it to enhance conversation or promote recall.  Sit so you are facing the person when speaking.  Avoid a setting with a lot of sensory stimulation—it can be distracting to the person.  Maintain eye contact; it will help keep the patient focused on you and the topic.  Be respectful of space. If the individual chooses to get up and start walking mid-conversation, ask if you may follow. Understanding  Speak in normal tones.  Use age-appropriate language.  Start with a familiar topic. Sometimes this means talking about the past, then through conversation bringing the person back to current circumstances.  Talk about people or events known to the person. This may mean referring to a deceased family member—the individual will let you know if this reference is comforting or distressing.  For many individuals, pleasant memories from the past are a source of comfort.  Orientation questions can be confusing and frustrating for the person, so rather than asking, “What’s today’s date?” consider asking, “Where’s the calendar? Let’s find today’s date and mark it so we can find it later.”  Ask one question at a time.  If the individual becomes upset or agitated, ease up and use distraction to change the topic or provide a period of quiet to allow a cool-down period. Communication  Show interest in the person.  If it is difficult to hear the person, gently ask his or her to speak louder.  Provide time for conversation. Sometimes it will take a while to get the message out. Sometimes it is easier for the person to tell a story than respond to a direct question.  Don’t laugh at responses, no matter how bizarre. Acknowledge your inability to understand and your frustration. It’s probably a mutual feeling that both parties share. 27 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  Communicating with Individuals with Aphasia Invite, Respect  Include the individual in conversations. Look at the person as well as others during conversation.  Treat the person as an adult.  Provide time for the individual to speak. Getting the message across is more important than perfection.  If you don’t understand the person, politely say so: “I’m sorry, I can’t understand what you are saying to me.”  Remember, frustration works both ways—it’s always better to end the conversation with a smile rather than a frown. Environment  Position yourself across from the person so they can see your face and you can see theirs. Understanding  Speak naturally. Don’t raise your voice—it won’t help.  Speak slowly using simple words and sentences.  Use simple gestures to supplement your message. (This isn’t a game of Charades or Pictionary—don’t get carried away with your gestures.)  Tell the patient one thing at a time. Announce topic changes and allow a few minutes before proceeding Communication  Provide time for the individual to speak.  Look at the person and listen as they speak.  If you don’t understand, ask them to describe the word, use another word, say or write the first letter, point to the item, or describe the context for use.  If the individual is able to write, ask them to write the word or use a word board to spell the word.  Follow instructions from the speech language pathologist to improve the consistency of communication. Communicating with Individuals with Visual Impairments Invite, Respect  Gently call out to the individual when entering the room and identify yourself and anyone with you in the room.  If the individual can see shapes or outlines, stand where he or she can see you.  The best location will vary—make a note on the medical record alerting other staff to the patient’s needs. Environment  Minimize distractions. Describe the environment and where you are located in relation to the person. 28 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114   Explain what you are doing, especially when you are moving and creating sounds in the room (e.g., storing dressing supplies in the closet, preparing equipment to draw blood, etc.).  Make certain not to move frequently used objects. Understanding  Alert the person when you will be touching them Communication  Oral communication with touch is more important than nonverbal gestures that they cannot see; use an appropriate tone of voice. Communicating with Individuals with Hearing Impairment Invite, Respect  To get the attention of the person, touch the person gently, wave, or use another physical sign.  Store assistive devices—hearing aid, notepad, and pen—within reach of the individual.  Make certain any emergency alarms essential for safety have a light or visual alert to get the individual’s attention in case of emergency.  Allow time for the conversation. Environment  If the individual uses a hearing aid, check to see whether he or she is wearing it and that it is turned on.  Minimize background noise (turn off the radio or TV and close the door to minimize distractions from the hall).  When speaking, face the person directly so he or she can see you Understanding  Speak clearly in a low-pitched voice; avoid yelling or exaggerating speaking movements—it won’t help.  Use short sentences.  Don’t hesitate to use written notes to maximize understanding and involve the person in the conversation.  Avoid chewing, eating, or smoking as you speak; they will make reading your speech more difficult.  Keep objects (e.g., scarf, hands) away from your face when speaking. Communication  Allow the individual to be involved in making decisions—don’t assume it takes too much time to ask.  Provide time for the individual to speak.  Ask questions to clarify the message; if needed, have the individual write a response. Communicating with Individuals Who Are Deaf Invite, Respect  Note on the patient’s record that the individual is deaf and may need an interpreter. 29 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114   Document if the individual uses American Sign Language or other assistive communication.  Use a TDD phone or relay service to communicate with the person.  Use an interpreter for conversations regarding health care decision making.  To get the attention of the person, touch the person gently, wave, or use another physical sign.  Store assistive devices—notepad and pen—within reach of the individual.  Make certain any emergency alarms essential for safety have a light or visual alert to get the individual’s attention in case of emergency.  Allow time for the conversation—functional as well as social. Environment  When speaking, face the person directly so that he or she can see your lips and facial expressions. The preferred distance is 3–6 feet from the person. Understanding  Don’t hesitate to use written notes to maximize understanding and involve the person in the conversation.  Avoid chewing, eating, or smoking as you speak—they will make reading your speech more difficult.  When using an interpreter, face the individual not the interpreter—when asking as well as listening to a response.  Be mindful of your nonverbal expressions during conversations—remember you are conversing with the person, not the interpreter. Communication  Allow the individual to be involved in making decisions—don’t assume it takes too much time to ask.  Provide time for the individual to return communication and keep your focus on the person.  Ask questions to clarify the message; if needed, have the individual write his/her response. C. Guidelines for Effective Documentation Purposes in the Care of Older Client (1) The recorded assessment provides the data needed for the careful development of the individualized plan of care and the evaluation of patient outcomes. (2) Documentation also provides the communication needed to ensure that a person continues to receive continuity of care—from one shift to another and one caregiver to another and across settings. 30 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  (3) Documentation is the major means for the nurse to demonstrate the quality of care he or she provides. (4) Documentation also serves as the basis for the determination of reimbursement in most settings. (5) The nursing records supplements documentation with more details regarding a person’s wishes and include who they want involved in their care, who they want to have access to their records, and their wishes related to everything from organ donation to the use of cardiopulmonary resuscitation (CPR) and the handling of their bodies after death. Documentation in Acute Care and Acute &Rehabilitation Care Settings 1. Electronic Medical Record - Computers can be found at the bedside, in nurses’ pockets, and in strategic locations around the unit. Nurses are given passwords that may be more important than their name tags. Bar codes and even fingerprints are scanned both for access to records, the administration of treatment and medications and the identification of patients 2. Care maps - used to predict and document the care provided within a preestablished trajectory and to anticipate the day of discharge. 3. Problem-oriented notes - The patient is assessed (usually with a checklist); problems are identified and care plans of interventions are developed. Documentation in Long-Term Care Facilities 1. In family care homes and assisted living facilities, documentation generally occurs only if a nurse has been hired or is under contract with the facility. This service is always optional and is usually limited to administration of medications or the delegation of this act to nurse’s aides. 2. Both nursing facilities and skilled nursing facilities nursing observations, documentation in these facilities encompasses the recording of day-to-day care such as eating and bowel movement as well as vital signs, periodic assessment, medication and treatment administration, assessment of any unusual event or change in condition, and periodic mandated comprehensive assessments. D. Geriatric Health Care Team Multidisciplinary teams - function as a group (multiple) of professionals who work loosely in the same area or with the same client. 31 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  - sequential, with each discipline applying their assessment and intervention within their own silo Interdisciplinary teams - are an interconnected group of professionals who have common and collective goals. - have an interactive approach to care. Disciplines, Education, Roles, and Web Resources in Gerontology Discipline Role in Gerontology Audiologist Assesses hearing including audiometric studies, evoked potentials, and other diagnostic procedures and treatment of hearing loss Religious workers, Provide support to the client/patient, family, and others as it Including chaplain, relates to spiritual needs. May assist in identifying resources priest, rabbi, minister from within congregation for support, visitation, or respite. Geriatrician Utilizes knowledge of normal aging as part of assessment. Specializes in the diagnosis and treatment of the elderly. Dietician Assesses nutritional status and implements nutritional plan. Advanced Provides primary care including history and physical, and gerontological chronic disease management. nurse practitioner Occupational Assesses and treats functional, sensory, and perceptual deficits Therapist that impact ADLs. Assesses need for assistive devices. Assesses and treats cognitive deficits. Provides rehabilitative services in geropsychiatric services. Pharmacist Prepares and dispenses medication. Provides clinical consultation and education for patient and geriatric team. Physical Assesses mobility and functional capacity of the elderly. Therapist Treatment includes rehabilitation, strengthening, mobility, and use of assistive devices. Psychiatrist Geropsychiatry. Evaluates, treats, and manages mental health issues faced by the elderly. Includes pharmacotherapy, evaluation of cognition, and psychotherapy. Psychologist Geropsychology. Assesses, consults, intervenes in, and manages conditions related to adaptation, bereavement, counseling, and treatment for clinical, cognitive, and behavioral needs Registered nurse Assesses, plans, provides, coordinates, and evaluates care, which focuses on health, optimal wellness, disease prevention, and 32 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  advocacy. Social worker Assists with coping and problem solving as individuals and families adjust to and face changes with aging and chronic illness. Provides counseling and psychotherapy. Speech-language Assesses and treats communication, disorders including speech, Pathologist language, and hearing, as well as swallowing and cognitive deficits. Clinical specialist Provides, directs, and influences care of older adults and in gerontological families in various settings nursing Activity 1 Case Study Ms. Espinoza is a 90-year-old Hispanic female admitted to the hospital from her assisted living facility. She has a history of hypertension and dementia, and had a stroke and a myocardial infarction 3 years ago. She has also had insomnia for the past month. Ms. Espinoza is admitted due to an alteration in her mental status. She has had a cold and a cough for a week, for which she took Coricidin (acetaminophen and chlorpheniramine) and Tylenol PM (acetaminophen and diphenhydramine). Her home medications include monthly Nascobal (vitamin B12) injections; Toprol-XL (metoprolol succinate), 100 mg daily; Plendil (felodipine), 10 mg daily; Allegra (fexofenadine), 180 mg daily; Ecotrin (aspirin EC), 325 mg daily; and Colace (docusate sodium), 100 mg daily. She also has a very unsteady gait. Ms. Espinoza’s admitting diagnosis is mnpneumonia. The physicians order the following medications: Lasix (furosemide), 20 mg IV push, x1; Pepcid (famotidine), 20 mg bid; Ecotrin (aspirin EC), 325 mg daily; Toprol-XL (metoprolol succinate), 100 mg daily; Colace (docusate sodium), 100 mg daily; Allegra (fexofenadine), 180 mg daily; Levoquin (levofloxacin), 250 mg daily IVPB; Plendil (felodipine), 10 mg po daily; and Ambien (zolpidem), 5 mg at bedtime as needed. Questions 1. Which medication(s) may have contributed to Ms. Espinoza’s altered mental status? 2. In addition to the drug regimen, does Ms. Espinoza have any other risk factors for altered mental status? 3. Would you alter her drug regimen in any way? If so, how? 33 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114 Activity 2: Case Study Mr. Bowen is 64 years old. He has been very healthy by report and very active working as a dairy farmer. He had a stroke affecting his right side 2 weeks ago and currently has a moderate leg weakness with a more significant arm weakness, slurred speech, and mild dysphagia (swallowing difficulty). He is predicted to be ambulatory with a cane, though prognosis of arm function returning is more guarded. It is likely he will improve speech function and swallowing ability but will require some specialization of diet to prevent aspiration. Mr. Bowen has chosen to stop eating, stating that he does not want to live as man invalid. His family is very distressed and wants him to be forced to eat. They cannot imagine why he has made this choice when his prognosis is so good compared to othersthey have seen in the rehabilitation setting with much more severe deficits. He has been evaluated for depression and an antidepressant has been recommended, which he refuses to take along with all other medications recommended for his newly diagnosed cardiovascular disease. Mr. Bowen is oriented and has not had represent a competence questioned prior to taking this stand. Some of the staff supports his decision and others do not. Discussion with the family reveals that Mr. Bowen has frequently made deriding remarks about persons with disability, including remarks like “If I ever end up that way, just take me out behind the barn and shoot me.” The psychologist comments that Mr. Bowen is frankly depressed andthat part of this depression is related to the location of his stroke. He also points out that he feels strongly that should the depression be resolved, Mr. Bowen would likely change his opinion. 1. How is this situation best handled? 2. Does Mr. Bowen have the right to refuse to eat and take medications when he is clearly not in an end-of-life situation? 3. How does the team resolve the situation when the depression is so prevalent and he refuses treatment for it? 4. Will you be able to care for Mr. Bowen if his wishes are granted? 34 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114 Activity 3 Sometimes, referral to hospice is provided at the very end of life. The patient and family are still able to benefit from the comfort philosophy when the life expectancy is hours or days, rather than weeks. However, the care may often be provided in a crisis-resolving mode, as evidenced in this case study. Jose is a 76-year-old man who has advanced prostate cancer, metastatic to the lungs. He has been treated with hormone injections for the past 4 years and has had radiation therapy. He has been functioning with the assistance of his wife Maria, has been able to go to lunch with his retired work buddies, and enjoyed sports and the nightly news on TV until about 1 month ago. Upon return home from his most recent hospitalization, Jose continued to have back pain (rated 7 on a 0–10 scale) unrelieved by hydrocodone. He is now increasingly weak, sleeping much of the day and night, and is short of breath with any exertion—even talking. He is disinterested in TV, newspapers, or other outside interests, and is consuming only bites and sips of food and fluids. Jose has voiced concerns about addiction to pain medications. His wife is unable to get him into the physician’s office for the scheduled follow-up visit, and calls the physician with concern about managing her husband’s care. Maria is crying and seems to be in a panic about how to manage her husband’s increasing needs—Jose seems to have a lot of pain, he is incontinent with increasing frequency, and has slipped to the ground with transfers to the bathroom overnight. The physician calls the home/hospice care agency with an order to evaluate Jose and Maria’s situation.Wishing to evaluate for the possibility of hospice care, the agency sends a nurse and social worker to evaluate the patient’s condition and caregiver status. Upon physical assessment, the nurse perceives that the patient’s time is short perhaps hours to a few days, not weeks. The social worker identifies that the wife, age 75, has a history of arthritis and high blood pressure, and will need assistance to provide for Jose’s much increased care needs. The couple has no children of their own, and Maria’s two adult children live on opposite sides of the country and are unaware of the most recent changes in their stepfather’s condition.Maria appears to be unaware of Jose’s end-of-life status. She is talking about building his strength, making his favorite foods so he’ll eat more, and arranging for him to attend the army reunion next month that he had solooked forward to. 35 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114  Questions: 1. What are your recommendations after the initial assessment? 2. How can you begin to alleviate Maria’s apparent denial about Jose’s condition? 3. What team members should be a part of Jose’s care plan? 4. How can we determine Jose’s goals for his end of life? 5. Evaluate Jose’s emotional status; how does it affect his daily functioning? How does it affect his relationship with his wife? How can other team members assist with these issues? 6. What impact do Jose’s spiritual life/beliefs have on his condition and functional ability? 7. How might hospice offer Maria assistance in meeting Jose’s physical care needs? 8. What can be done for Jose’s symptoms? How would you address Jose’s addiction concerns, in light of the fact you believe he needs a stronger opioid? 9. What support will Maria need in keeping Jose at home? 10. What other care options exist to provide Jose and Maria? Activity 4 A student nurse on rounds enters a patient’s room and finds an olderwoman sitting comfortably in a wheelchair in no apparent distress staring outthe window with her back to the nurse. Is this patient inviting communication from the nurse? Based on the patient’s position and posture, the nurse may elect to not speak or say anything fearing she might disturb the patient. Shortly the staff nurse enters the room and comments, “Mrs. Hale, are you waiting for someone? Can I do anything to help you get ready for a visit?” Mrs. Hale responds “I am waiting for my son. He is generally on time. I hope nothing bad has happened. I would like to go the bathroom before he arrives so I don’t have to worry about that during his visit.” What is the nurse’s most appropriate response in this situation? Should the nurse have done anything differently during the first visit to the room on rounds? If so, what? What nonverbal communication would the nurse expect to see from Mrs. Hale? What nonverbals should the nurse include in her care of this woman? 36 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114 Activity 5 Mr. J., an 84-year-old man, has Type 2 diabetes and hypertension. He notices some decrease in his activities of daily living due to unsteadiness on his feet. He is mourning the loss of his wife, who died 6 months ago. His daughterin- law is concerned about the number of medications he is on and if he is taking them correctly. Mr. J. has been eating frozen dinners and spends most of his days sitting in the front room watching television. Questions: 1. Who is the correct person for him to see? the physician, the social worker, the registered pharmacist, the dietician, the physical therapist, or the occupational therapist? 2. Should the physician be an internist, an endocrinologist, a psychiatrist, or a gerontologist? 3. Should Mr. J. see all of these individuals and have multiple evaluations, treatment plans, and follow-up appointments? 4. Which professional should he see first? 5. Is it possible for the different treatment plans to be duplicative or counterproductive to each other? Reflections on the Case Study The assessment team for Mr. J. in the case study may include a geriatrician, gerontological nurse practitioner, social worker, dietician, physical and occupational therapist, pharmacist, and psychologist or psychiatrist. Together they could assess Mr. J. for diabetes control and the presence of peripheral neuropathy, which may be affecting his mobility and rule out a minor stroke given his history of hypertension and diabetes. From that point they could assess his need for physical or occupational therapy for functional mobility. The dietician could analyze his diet and, based on Mr. J.’s diabetes, recommend dietary needs. Depending on the assessment for grieving or depression, recommendations for counseling, medication, or socialization might be needed. Referrals could be made as needed for Meals on Wheels or for some socialization activities at a senior center. 37 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114 Wrap-up Activity: Nurses must respect the worth, dignity, and rights of the elderly and must provide care that meets their comprehensive needs across the continuum. Their fundamental commitment to the uniqueness of the patient creates opportunities for participation in planning and directing care. Their vigilance in advocating for dignified, just, and humane care establishes a standard that can be appreciated, and potentially needed, by all of us. It is not the rules and regulations that create ethical care delivery; it is the little actions done by each and every nurse in every day of practice. In summary, palliative care is an interdisciplinary care that is focused on relieving suffering and improving quality of life for patients and families living with chronic serious illness. It is neither end-of-lifecare nor hospice, and it is offered simultaneously with all other appropriate medical treatments. As the population of older adults continues to rise, the number of special problems that affect the quality of life unique to this population will expand. Regardless of the trajectory of these quality of life issues among older adults, nurses are in a key position to assess older adults for the risk and existence of these commonly occurring issues and implement strategies to reduce their negative consequences. In so doing, nurses can promote a high quality of life for older adults in all care settings. Post Assessment Activity A quiz will be uploaded in mVLE after your discussion. References: Kane, R. L., Ouslander, J. G., &Abrass, I. B. (2013). Essentials of clinical geriatrics. New York: McGraw-Hill, Health Professions Division. https://www.officialgazette.gov.ph/2010/02/15/republic-act-no-9994/ https://www.comelec.gov.ph/?r=References/RelatedLaws/ElectionLaws/PWDandSeniors/RA7432 https://www.officialgazette.gov.ph/2004/02/06/republic-act-no-9257/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4573668/ Touhy, T. A., Jett, K. F., & Ebersole, P. (2014). Ebersole and Hess' gerontological nursing & healthy aging. 4th ed. St. Louis, Mo.: Elsevier/Mosby. 38 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114 https://www.researchgate.net/publication/279807586_Information_Sharing_Preferences_of_Olde r_Patients_and_Their_Families Fitzwater, C. 2011.Look Close See Me, Aging & Communications: Engaging Older People. University of Cincinnati College of Nursing 39 | MMSU-CHS-DEPARTMENT OF NURSING NCM 114