COA-module PDF - Care Of Older Adult

Care of Older Adult INSTRUCTOR’S GUIDE BS NURSING / THIRD YEAR Session # 1 LESSON TITLE: INTRODUCTION TO...

Care of Older Adult INSTRUCTOR’S GUIDE BS NURSING / THIRD YEAR Session # 1 LESSON TITLE: INTRODUCTION TO GERONTOLOGIC NURSING Materials: Book, pen and notebook LEARNING OUTCOMES: References: Upon completion of this lesson, the nursing student can: Mauk, K. L. (2018). Gerontological Nursing: 1. Integrate principles and concepts of physical, social, natural Competencies for Care (4th ed.). Jones & Bartlett and health sciences and humanities in the care of older adults. Learning. 2. Demonstrate, by application within the clinical area, the https://geriatricnursing.org/author/admin/. (2020, knowledge on the roles and responsibilities of a gerontologic September 9). 09 Sep Overview of Aging. nurse GeriatricNursing.Org. https://geriatricnursing.org/overview-of-aging/ SUBJECT ORIENTATION & GETTING TO KNOW EACH OTHER ACTIVITY (10 minutes) The instructor will be starting to introduce himself/herself to the class and the assigned subject, Care of the Older Adult. The course outline will be distributed and discussed accordingly. Listed below are the additional information vital in orientation: 1. The calendar of activities for major examinations must be relayed. 2. Classroom rules and regulations will be informed per the instructor’s discretions. 3. Computation of grades specific for this subject must be thoroughly explained to students. 4. The essence and significance in grade computation of these modules must be introduced. 5. If this is the first subject of the class, the instructor must initiate an election for block officers. Any other information that will be deemed necessary by the instructor must be properly coordinated Brain Teaser Questions: The Instructor will ask the students to answer the following questions. 1. Think of the movies and television shows you have watched recently. How were older actors portrayed? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 2. What are your views and perception of old age and older adults? __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ MAIN LESSON (20 minutes) The instructor should discuss the following topics. Instruct students to take down notes. INTRODUCTION TO GERONTOLOGIC NURSING Geriatric or gerontological nursing is one of the fields of nursing that deals with proper care and hospitalization of aged or geriatric patients. This specialized field is very intricate as it involves understanding the aging process and the tremendous changes that every individual has to face. Life expectancy is steadily increasing. Thus, nurses are expected to care for a relatively large number of the elderly in the coming decades. A nurse’s role in this specialized field is critical in promoting active aging and she should be able to care for various diseases and conditions characteristic of the aged in the process. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 1 of 5  Caring for the aged is not a new concept in nursing; Florence Nightingale pioneered this specialized field. She was renowned as the first geriatric nurse because of her nurse superintendent position in an English institution, where she cared for helpers and maids of wealthy women. Nowadays, gerontological care is recognized by society through the collaboration of several organizations and hardworking individuals in the field of nursing. In time, geriatric nurses trained for the job and an evidence-based geriatric nursing practice was developed, which allowed the production of books, journals, websites and even organizations dedicated to caring for older adults. DEFINITION OF TERMS  Gerontology – It is the study of aging and/or the aged. This includes the biopsychosocial aspects of aging.  Geriatrics – This term is often used as a generic term relating to the aged, but specifically refers to medical care of the aged.  Gerontological Nursing- It is the aspect of gerontology that falls withing the discipline of nursing and the scope of nursing practice.  Old age – often defined as over 65 years of age  Gerontological rehabilitation nursing - combines expertise in gerontological nursing with rehabilitation concepts and practice.  Social Gerontology- concerned mainly with the social aspects of aging  Geropsychology- refers to specialists in psychiatry whose knowledge, expertise, and practice are with the older population.  Financial Gerontology – another emerging subfield that combines knowledge of financial planning and services with a special expertise in the needs of older adults. ROLES OF GERONTOLOGICAL NURSE Provider of Care Teacher An essential part of all nursing is teaching. An essential part of all nursing is teaching. Gerontological nurses focus their teaching on Gerontological nurses focus their teaching on modifiable risk factors. Many diseases of aging modifiable risk factors. Many diseases of aging can be prevented through lifestyle can be prevented through lifestyle modifications such as a healthy diet, smoking modifications such as a healthy diet, smoking cessation, appropriate weight maintenance, cessation, appropriate weight maintenance, increased physical activity, and stress increased physical activity, and stress management. management. Manager Advocate As an advocate, the gerontological nurse acts Gerontological nurses act as managers during on behalf of older adults to promote their best everyday care as they balance the concerns of interests and strengthen their autonomy and the patient, family, nursing, and the rest of the decision making. Advocacy may take many interdisciplinary team. Nurse managers need forms, including active involvement at the to develop skills in staff coordination, time political level or helping to explain medical or management, assertiveness, communication, nursing procedures to family members on a and organization. unit level. Nurses may also advocate for patients through other activities such as helping family members choose the best Research Consumer nursing home for their loved one or listening to family members vent their frustrations about health problems encountered. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 2 of 5  The appropriate level of involvement for nurses at the baccalaureate level is that of research consumer. This involves gerontological nurses being aware of current research literature, continuing to read and put into practice the results of reliable and valid studies. Using evidence-based practice, gerontological nurses can improve the quality of patient care in all settings. CHECK FOR UNDERSTANDING (15 minutes) The instructor will instruct the students to answer the ten (10) questions and write the rationale for each question. One (1) point will be given to correct answer and another one (1) point for the correct ratio. The students will be given 15 minutes for this activity. Multiple Choice (For 1-10 items, please refer to the questions in the Rationalization Activity) RATIONALIZATION ACTIVITY (10 minutes) The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss among their classmates for (ten) 10 minutes. 1. Which of the following improves attitudes toward aging and older adults? a. Staying away from older adults b. Education about older adults c. Travelling to older communities d. Watching the portrayals of older adults in movies and on TV Answer: B. Education about older adults Rationale: Education about older adults provides essential information needed to understand aging process and care. 2. What best describes nurses as a care provider? a. Determine client’s need b. Provide direct nursing care c. Help client recognize and cope with stressful psychological situation d. Works in combined effort with all those involved in patient’s care Answer: A. Determine client’s need Rationale: The best description of a care provider is the accurate and prompt determination of the client’s need to be able to render an appropriate nursing care. 3. As a student nurse, you understand that it is important to study Gerontological Nursing because: a. it is fixed and unchanging. b. it provides a way to understand the aging process and provide quality care to older adults c. it can help predict the responses that the body can do in during aging. d. it gives positive outlook to older adults. Answer: B. It provides a way to understand the aging process and provide quality care to older adults Rationale: Gerontological Nursing gives essential information needed by students to provide quality care to older adults and presented with knowledge and insights from experienced professionals with expertise in various areas of geriatrics. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 3 of 5 4. Nurse Beth told Mr. Dela Cruz about ways to decrease the risk of heart disease. What role of a gerontologic nurse did Nurse Beth portray? a. Manager b. Advocate c. Teacher d. Provider of Care Answer: C. Teacher Rationale: Giving health teachings to patients is the essential part of all nursing. 5. Nurse Beth explains medical and nursing procedures to Mr. Dela Cruz’s family members. What role did Nurse Beth play in this situation? a. Manager b. Advocate c. Teacher d. Provider of Care Answer: B. Advocate Rationale: Being an advocate strengthen the patient’s autonomy and decision making. Advocacy may take many forms, including active involvement at the political level or helping to explain medical or nursing procedures to family members on a unit level. 6. What role involves gerontological nurses being aware of current research literature, continuing to read and put into practice the results of reliable and valid studies? a. Research Consumer b. Advocate c. Teacher d. Provider of Care Answer: A. Research Consumer Rationale: Using evidence-based practice, gerontological nurses can improve the quality of patient care in all settings. All nurses should read the journals specific to their specialty and continue their education by attending seminars and workshops, pursuing additional formal education or degrees, or obtaining certification. Any of these activities promote the role of the nurse as research consumer. 7. As a nurse manager, Nurse Beth knows that she needs to develop the following skills except; a. Time management b. Assertiveness c. Staff insubordination d. Communication Answer: C. Staff Insubordination Rationale: A,B,and D are essential skills to be developed as a nurse manager. Staff insubordination hinders the goal of balancing the concerns of the patient, family, nursing, and the rest of interdisciplinary team. 8. A primary care provider’s order indicate that a consent form needs to be signed. Since the nurse was not present when the primary care provider discussed the procedure, which statement best illustrates the nurse fulfilled the client advocate role? a. “The doctor has asked that you sign this consent form.” b. “Do you have any questions about the procedure?” c. “What were you told about the procedure you are going to have?” d. “Remember that you can change your mind and cancel the procedure.” Answer: C. “What were you told about the procedure you are going to have?” Rationale: This response helps the patient voice out his/her understanding of the procedure. With this, the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. 9. A nurse who reads research articles and incorporates research findings into nursing practice would demonstrate which of the following roles? This document and the information thereon is the property of PHINMA Education (Department of Nursing) 4 of 5  a. Collaborator b. Primary Investigator c. Producer d. Consumer Answer: D. Consumer Rationale: Nurses who provide patient care will be consumers of nursing research, implementing evidence- based nursing practice is crucial to provide optimal nursing care. 10. The nurse clarifies to a group of clients that the field of nursing interest that specializes in disease prevention, increasing autonomy and self care, and maintenance of function for older adults is a. gerontology. b. geriatrics. c. developmental psychology. d. public health. Answer: A. Gerontology Rationale: Gerontology is the specialty in the care of older adults focusing on disease prevention, health promotion, and maintenance of optimal independent functioning. LESSON WRAP-UP (5 minutes) Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track how much work they have accomplished and how much work there is left to do. This tracker will be part of the student activity sheet. You are done with the session! Let’s track your progress. AL Activity: One- Minute Paper: The students will be asked to provide written feedback of the following questions on an index card: a. What was the most important thing you have learned during class? b. What important question do you have as we end this session? (For Related Learning Experience, please refer to your clinical instructor.) This document and the information thereon is the property of PHINMA Education (Department of Nursing) 5 of 5  Care of Older Adult INSTRUCTOR’S GUIDE BS NURSING / THIRD YEAR Session # 2 LESSON TITLE: STANDARDS AND GERONTOLOGIC Materials: NURSING PRACTICE/ PERSPECTIVE OF AGING Book, pen and notebook LEARNING OUTCOMES: References: Upon completion of this lesson, the nursing student can: Mauk, K. L. (2018). Gerontological Nursing: Competencies for Care (4th ed.). Jones & Bartlett 1. Integrate principles and concepts of physical, social, natural Learning. and health sciences and humanities in the care of older adults. 2. Apply appropriate nursing concepts and actions holistically and comprehensively. 3. Provide appropriate evidence-based practice in the nursing care of alder adults 4. Manifest professionalism, integrity and excellence. 5. Integrate principles and concepts of physical, social, natural and health sciences and humanities in the care of older adults. 6. Apply appropriate nursing concepts and actions holistically and comprehensively. LESSON REVIEW (5 minutes) The instructor should summarize the previous topic. Explain the Hook Activity. Case Study: Instruct the students to read the Case Study and answer the question briefly. Case Study: What roles of a nurse did Nurse Jerry fulfill to his patients? Jerry is a new BSN graduate who has been hired on the skilled care unit in a nursing home. He Provider of Care- provides hands-on care to his patients. He makes provides hands-on care to his sure that the patient’s care is cohesive and patients. coordinates to other healthcare workers. Nurse Manager- He coordinates to other healthcare This document and the information thereon is the property of PHINMA Education (Department of Nursing) 1 of 7 MAIN LESSON(25 minutes) The instructor should discuss the following topics. Instruct students to take down notes and read their book about this lesson. Standards of Practice Standards of nursing practice developed by the American Nurses’ Association (ANA) provide guidelines for nursing performance. They are the rules or definition of what it means to provide competent care. The registered professional nurse is required by law to carry out care in accordance with what other reasonably prudent nurses would do in the same or similar circumstances. Thus, provision of high quality care consistent with established standards is critical. ANA STANDARDS OF GERONTOLOGICAL NURSING PRACTICE Nursing Care STANDARD I. Assessment: The gerontological nurse collects patient health data. STANDARD II. Diagnosis: The gerontological nurse analyzes the assessment data in determining diagnoses. STANDARD III. Outcome Identification: The gerontological nurse identifies expected outcomes individualize to the older adult. STANDARD IV. Planning: Develops a plan of cares that prescribes interventions to attain outcomes. STANDARD V. Implementation: Implements the interventions identified in the of core. STANDARD VI. Evaluation: Evaluates the older adults progress towards attainment of expected outcomes. Quality Care STANDARD I. Quality of Care: The gerontological systemically evaluates the quality of care and effectiveness of nursing practice. STANDARD II. Performance Appraisal: The gerontological nurse evaluates his/her own nursing practice in relation to professional practice standards and relevant statutes and regulations. STANDARD III. Education. The gerontological nurse acquires and maintains current knowledge in nursing practice. STANDARD IV. Collegiality: Contributes to professional development of peers, colleagues and others. STANDARD V. Ethics: Decisions and actions on behalf of older adults are determined in an ethical manner. STANDARD VI. Collaboration: Collaborates with older adults, the older adults caregiver, and all member of interdisciplinary team to provide comprehensive care. STANDARD VII. Research: Interprets applies and evaluates research findings to improved gerontological nursing practice. STANDARD VII. Resource Utilization: Considers the factors related to safety, effectiveness and cost in planning and delivering patient care. 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 in older adults and refer appropriately. 7. Implement strategies and use online guideline 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 adult. 9. Recognize the complex interaction of acute and chronic comorbid physical and mental conditions and association 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. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 2 of 7  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 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 (e.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 for older adults with physical and cognitive impairments. 17. Implement and monitor strategies to prevent risk and promote quality and safety in the nursing care of 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 the older adults. Perspective of Aging A. Aging is a developmental process Starts at birth Gradual changes in body structures and systems Not all changes at the same rate and same impact Changes can impact function, participation and quality of life Every living organism begins aging from the time of conception. The process of maturing or aging helps the individual achieve the level of cellular, organ and system function necessary for the accomplishment of life tasks. Constantly and continuously, every cell of every organisms ages. Despite the normality and naturalness of this experience, many people approach aging as though it were a pathological experience. Aging is not a crippling disease; even with limitations that would be imposed by pathologies of late life, opportunities for usefulness, fulfillment, and joy are readily present. A realistic understanding of aging process can promote attitude to old age. A. Demographic of Aging and Implications for Health and Nursing Care 1. Global Aging The world is on the brink of a demographic milestone. Since the beginning of recorded history, young children have outnumbered the number of people aged 65 or older will outnumber children under age 5. Driven by falling fertility rates and remarkable increases in life expectancy, population aging will continue, even accelerate. The number of people aged 65 or older is projected to grow from an estimated 524 million in 2010 to nearly 1.5 billion in 2050, with most of the increase in developing countries. Aging is taking place alongside other broad social trends that will affect the lives of older people. Economies are globalizing, people are more likely to live in cities, and technology is evolving rapidly. Demographic and family changes mean there will be fewer older people with families to care for them. People today have fewer children, are less likely to be married, and are less likely to live with older generations. With declining support from families, society will need better information and tools to ensure the well-being of the world’s growing number of older citizens. Although the future direction of health care is uncertain, it can confidently be surmised from the demographic profile that nurses in a wide variety of settings and roles will be challenged to provide care to an increasingly divergent, complex group of older persons. An urgent need exists for gerontologic nurses to (1) create roles that meet the needs of the older population across the continuum of care; (2) develop models of care delivery directed at all levels of prevention, with special emphasis on primary prevention and health promotion services in community-based settings; and (3) assume positions of leadership and influence not only in institutions and settings where care is currently provided to older persons but also in political arena.The overriding fact to remember is that the majority of problems experienced by older adults fall within the scope of nursing practice. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 3 of 7  2. Aging in the Philippines In the Philippines, the number of older people is increasing rapidly, faster than growth in the total population. In 2000, there were 4.6 million senior citizens (60 years or older), representing about 6% of the total population. In two decades, this has grown to 9.4 million older people or about 8.6% of the total population. The World Population Prospects 2019 projects that by 2050, older people will make up around 16.5% of the total population. An ageing population increases the demand for health services. Older people suffer from both degenerative and communicable diseases due to the ageing of the body’s immune system. The leading causes of morbidity are infections, while visual impairment, difficulty in walking, chewing, hearing, osteoporosis, arthritis and incontinence are other common health-related problems. Impact of Aging Members in the Family Many of our older individuals experience a decline in their physical and cognitive functioning. This has made them lose the ability to live independently, forcing them to seek long-term care services from institutions like long-stay hospitals, nursing homes, residential care and assisted living facilities. Families with older people often carry the burden of caring for these individuals, accumulating significant costs when they do. In less developed countries where affordable long-term care facilities are not available, families with elderly adults withdraw from their employment or school commitments just to care for these family members and make ends meet. They may end up with significant debt due to their hospitalization, medication maintenance, and home care adjustment costs. The impact of having an aging family member often varies on how well they handle the changes and demands of day- to-day living. Most families with a solid economic background and strong financial support from the government seek long-term nursing services to care for the elderly. Unfortunately, this may not apply to families with fewer resources and unemployed family members. The demands of an elderly individual are often unpredictable and changing. Thus, families should be prepared for this day to balance the situation and ensure the provision of a safe retirement for their loved ones. CHECK FOR UNDERSTANDING (15 minutes) The instructor will instruct the students to answer the ten (10) questions and write the rationale for each question. One (1) point will be given to correct answer and another one (1) point for the correct ratio. They are given 15 minutes for this activity. Multiple Choice (For 1-10 items, please refer to the questions in the Guided / Rationalization Activity) RATIONALIZATION ACTIVITY (10 minutes) The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss among their classmates for (ten) 10 minutes. 1. An 80-year-old patient, who lives at home with a spouse, is instructed to follow a 2 g sodium diet. The patient states, "I've always eaten the same way all my life, and I'm not going to change now." To promote optimal dietary adherence, the gerontological nurse's initial approach is to: a. inform the patient about the need to follow the diet. b. inquire about the patient's current food preferences and eating habits. c. list the variety of foods that are allowed on the diet. d. provide dietary instruction to the patient's spouse, who prepares the meals. Answer: B. Inquire about the patient's current food preferences and eating habits. Rationale: Provision of food that is similar to that which is eaten at home has been associated with better food intake and greater enjoyment of meals. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 4 of 7  2. Which best describes what guides the appropriate nursing care of an aging adult? a. Evidence-based practice developed with ongoing research into the needs and outcomes of older adults b. General nursing care previously practices c. Facility policies and procedures d. Physician orders for patient complaints Answer: A. Evidence-based practice developed with ongoing research into the needs and outcomes of older adults Rationale: EBP in nursing is an integration of research evidence, clinical expertise and a patient's preferences. This problem-solving approach to clinical practice encourages nurses to provide individualized patient care. 3. When teaching an independent older adult patient how to self-administer insulin, the most productive approach is to: a. facilitate involvement in a small group where the skill is being taught. b. gather information about the patient's family health history. c. provide frequent, competitive skills testing to enhance learning. d. use repeated return demonstrations to promote the patient's retention of the involved tasks. Answer: D. Use repeated return demonstrations to promote the patient's retention of the involved tasks Rationale: Return demonstrations are important for elderly patients to ensure that they are able to do psychomotor skills independently. To increase learning for elderly patients, repeat the message frequently, and question the patient regularly to determine the level of retention. 4. A 90-year-old patient comes to the clinic with a family member. During the health history, the patient is unable to respond to questions in a logical manner. The gerontological nurse's action is to: a. ask the family member to answer the questions. b. ask the same questions in a louder and lower voice. c. determine if the patient knows the name of the current president. d. rephrase the questions slightly, and slowly repeat them in a lower voice. Answer: D. Rephrase the questions slightly, and slowly repeat them in a lower voice. Rationale: Select clear, simple, terminology, and talk on the patient’s level. Some elderly patients are highly educated and will prefer that you use and explain medical terminology; others will prefer that you keep interactions short and simple. Some elders have increasing difficulty understanding complex sentences. Present new information at a slower rate than you do for younger patients. Speak in a low tone of voice and allow enough time for the patient to assimilate and integrate conceptual material. 5. The American Nurses Association's Gerontological Nursing: Scope and Standards of Practice emphasizes: a. that abnormal responses to the aging process determine the appropriate nursing diagnoses. b. that the health status data of older adult patients be documented in a retrievable form. c. the role of the older adult patient as the sole decision maker in planning his or her care. d. the unchanging nature of the goals and plans of care for older adult patients. Answer: B. That the health status data of older adult patients be documented in a retrievable form. Rationale: A Medical Record shall be maintained for every individual who is evaluated or treated. Documentation that comprises the Medical Record may physically exist in separate and multiple locations in both paper-based and electronic formats. 6. The nurse is aware that the majority of older adults: a. Live alone b. Live in institutional settings c. Are unable to care for themselves d. Are actively involved in their community Answer: D. Are actively involved in their community Rationale: Majority of the older adults ages 65 and above are in their household and still doing their daily activities. Most of the older adult are also actively participating in community activities. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 5 of 7  7. Which choice best explains the practice setting for the gerontological nurse? a. In the home of the client b. Only in acute care settings c. Clinics and long-term care facilities d. Home of the client, acute care facilities, long-term care settings, and clinics or anywhere clients over the age of 65 seek health care and health education Answer: D. Home of the client, acute care facilities, long-term care settings, and clinics or anywhere clients over the age of 65 seek health care and health education Rationale: Geriatric nurses are often employed at healthcare facilities such as hospitals and clinics. They also work in residential care facilities, like nursing homes and retirement communities. Some geriatric nurses also work in home healthcare, traveling to patients' homes to care for them there. 8. A 70-year-old presents to the clinic stating that his family thinks he is losing his mind and they want to put him in a home. What would be the initial role of the gerontological nurse? a. Begin the process of finding a qualified nursing home b. Do a complete history,physical, and assessment c. Speak with the family about their concerns d. Make light of the subject until the nurse can evaluate the situation Answer: B. Do a complete history,physical, and assessment Rationale: As part of the nursing process, the first step is to do a thorough assessment. 9. An 87-year-old man, who has been living independently, is entering a nursing home. To help him adjust, the most effective action is to: a. involve him in as many activities as possible so he can meet other residents. b. move him as quickly as possible so that he does not have time to think. c. restrict family visits for the first two weeks to give him time to adjust. d. suggest that he bring his favorite things from home to make his room seem familiar. Answer: D. Suggest that he bring his favorite things from home to make his room seem familiar. Rationale: Letting patients bring their valuable things from home helps elders feel they still have access to their possessions. This helps the patient adapt to his or her new environment. 10. Members of a family are caring for their father at home. Which statement by a family member indicates a need for teaching and caregiver instruction? a. "Dad has gotten lazy about his bathroom habits. He blames his arthritis medication for his toileting accidents." b. "Dad's room is close to the bathroom and we keep a light on for him at night." c. "It's inconvenient, but we stop other activities to remind Dad to go to the bathroom on a regular schedule." d. "We try to avoid coffee and tea at night, but Dad really likes a cup of coffee for breakfast." Answer: A. "Dad has gotten lazy about his bathroom habits. He blames his arthritis medication for his toileting accidents." Rationale: Osteoarthritis (OA) is a classic age-related disorder. It is often described as a chronic degenerative disease and thought by many to be an inevitable consequence of growing old. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 6 of 7 LESSON WRAP-UP (5 minutes) Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track how much work they have accomplished and how much work there is left to do. This tracker will be part of the student activity sheet. You are done with the session! Let’s track your progress. CAT: Muddiest Point The instructor asks students response to this one question: “In today’s session, what was least clear to you?” (For Related Learning Experience, please refer to your clinical instructor.) This document and the information thereon is the property of PHINMA Education (Department of Nursing) 7 of 7  Care of Older Adult INSTRUCTOR’S GUIDE BS NURSING / THIRD YEAR Session # 3 LESSON TITLE: BIOLOGICAL AND PSYCHOSOCIAL Materials: THEORIES OF AGING/ NURSING THEORIES OF AGING Book, pen and notebook LEARNING OUTCOMES: Upon completion of this lesson, the nursing student can: 1. Apply appropriate nursing concepts and actions holistically References: and comprehensively. Kristen L. Mauk (Editor). (2018). Gerontological 2. Integrate principles and concepts of physical, social, natural Nursing : Competencies for Care(4th ed). Jones & and health sciences and humanities in the care of older adults. Bartlett Pub. 3. Demonstrate understanding of human aging as a combination of psychological, social, and biological processes. 4. Apply appropriate nursing concepts and actions holistically and comprehensively. 5. Develop nursing interventions based on the psychosocial issues and biologic changes associated with older adult. 6. Demonstrate understanding of human aging as a combination of psychological, social, and biological processes. LESSON PREVIEW/REVIEW (5 minutes) The instructor should summarize the previous topic. Explain the Hook Activity. Brain Teaser Question: The instructor will ask the students to answer the question for at least 5 sentences. Imagine yourself at age 75. Describe your appearance, your health issues, and your lifestyle. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ MAIN LESSON (25 minutes) The instructor should discuss the following topics. Instruct students to take down notes. Theories of Aging Human aging is influenced by a composite of biologic, psychologic, social, functional, and spiritual factors. Aging may be viewed as a continuum of events that occur from conception to death (Ignatavicius and Workman,2005). Biologic, social, and psychologic theories of aging attempt to explain and explore the various dimension of aging. I. Biological Theories of Aging Theory Description This document and the information thereon is the property of PHINMA Education (Department of Nursing) 1 of 7  A. Stochastic Theories Based on random events that cause cellular damage that accumulates as the organisms ages. Free radical theory Membranes, nucleic acids, and proteins are damaged by free radicals, which causes cellular injury and aging. Error theory Errors in DNA and RNA synthesis occur with aging Wear and tear theory Cells wear out and cannot function with aging. Connective tissue/cross-link With aging, proteins impede metabolic processes and cause theory trouble with getting nutrients to cells and removing cellular waste products. B. Nonstochastic Theories Based on genetically programmed events that cause cellular damage that accelerates aging of the organism. Programmed Theory Cells divide until they are no longer able to, and this triggers apoptosis or cell death. Gene/biological clock theory Cells have a genetically programmed aging code Neuroendocrine theory Problems with the hypothalamus-pituitary-endocrine gland feedback system cause disease; increased insulin growth factor accelerates aging. Immunological theory Aging is due to faulty immunological function, which is linked to general well-being. I. PSYCHOSOCIAL THEORIES OF AGING Theory Description A. Sociological Theories Changing roles, relationships, status, and generational cohort impact the older adult’s ability to adapt. Activity Disengagement Remaining occupied and involved is necessary to a satisfying late-life. Gradual withdrawal from society and relationships serves to maintain social equilibrium and promote internal reflection Subculture The elderly prefer to segregate from society in an aging subculture sharing loss of status and societal negativity regarding the aged. Health and mobility are key determinants of social status. Continuity Personality influences roles and life satisfaction and remains consistent throughout life. Past coping patterns recur as older adults adjust to physical, financial, and social decline and contemplate death. Identifying with one’s age group, finding a residence compatible with one’s limitations, and learning new roles postretirement are major tasks. Age stratification Society is stratified by age groups that are the basis for acquiring resources, roles, status, and deference from others. Age cohorts are influenced by their historical context and share similar experiences, beliefs, attitudes, and expectations of life course transitions. Person-Environment Fit Function is affected by ego strength, mobility, health, cognition, sensory perception, and the environment. Competency changes one’s ability to adapt to environmental demands Gerotranscendence The elderly transform from a materialistic/rational perspective toward oneness with the universe. Successful transformation includes an outward This document and the information thereon is the property of PHINMA Education (Department of Nursing) 2 of 7  focus, accepting impending death, substantive relationships, intergenerational connectedness, and unity with the universe. B. Psychological Theories Explain aging in terms of mental processes, emotions, attitudes, motivation, and personality development that is characterized by life stage transitions. Human needs Five basic needs motivate human behavior in a lifelong process toward need fulfillment. Individualism Personality consists of an ego and personal and collective unconsciousness that views life from a personal or external perspective. Older adults search for life meaning and adapt to functional and social losses. Stages of personality development Personality develops in eight sequential stages with corresponding life tasks. The eighth phase, integrity versus despair, is characterized by evaluating life accomplishments; struggles include letting go, accepting care, detachment, and physical and mental decline. Life-course/lifespan development Life stages are predictable and structured by roles, relationships, values, and goals. Persons adapt to changing roles and relationships. Age group norms and characteristics are an important part of the life course. Selective optimization with Individuals cope with aging losses through activity/role selection, compensation optimization, and compensation. Critical life points are morbidity, mortality, and quality of life. Selective optimization with compensation facilitates successful aging. Implications for Nursing  Nursing has incorporated psychosocial theories such as Erikson’s personality development theory into its practice (Erikson, 1963).  Psychological theories enlighten us about the development tasks and challenges faced by older adults and the importance of finding and accepting meaning in one’s life.  From sociologists, nursing has learned how support systems, functionality, activity and role engagement, cohorts, and societal expectations can influence adjustment to aging and life satisfaction.  Nurses can learn from these theories to help minimize the challenges of aging by connecting older adults to resources.  These may include an occupational therapist that can help families adapt a home environment to that it is safe for an older adult to “age in place,”suggesting visiting aging. Nursing Theories of Aging Functional consequences theory Environmental and biopsychosocial consequences impact functioning. Nursing’s role is risk reduction to minimize age-associated disability in order to enhance safety and quality of living. Theory of thriving Failure to thrive results from a discord between the individual and his or her environment or relationships. Nurses identify and modify factors that contribute to disharmony among these elements. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 3 of 7 Theory of Successful Aging According to this theory, aging successfully means remaining physically, psychological, and socially engaged in meaningful ways that are individually defined. Achieving a comfortable acceptance of impending death is also a hallmark of successful aging.  Aging is a progressive process adaptation  Aging may be successful or unsuccessful depending upon a person’s ability to cope,  Successful aging is influenced by a person’s choices, and  Aging people experience changes, which uniquely characterize their beliefs and perspectives in ways that differ from those of younger adults (Flood, 2006) In conclusion, Nursing theories of thriving and functionality contribute to our understanding of aging; however, neither encompass all of the holistic elements of concern to nursing. Flood’s theory of successful aging provides a more comprehensive framework to guide nursing practice and has been validated by some authors; however additional studies are needed to confirm this theory. Given the diversity of older adults living in independent, assisted, and residential care settings, much can be learned from the theories of other disciples. From the stochastic and programmed biological theories of aging, nurses can better manage nutrition, incontinence, sleep rhythms, immunological response, catecholamine surges, hormonal and electrolyte balance, and drug efficacy for older adults with chronic illnesses. Using psychosocial aging theories, nurses can assist both the older adult and his or her family in recognizing that the life they have lived has been one of integrity and meaning and facilitate peaceful death with dignity. Ego integrity contributes to older adults’ well-being and reduces the negative psychological consequences that are often linked to chronic illness and older age. Finally, being cognizant of older adult’s socioeconomic resources will assist the nurse and older adult in planning cost-effective best practices to improve symptom management and treatment outcomes. Using knowledge gained from aging theories, nurses can:  Help people to use their genetic make-up to prevent comorbidities  Facilitate best practices for managing chronic illnesses  Maximize individual’s strengths relative to maintaining independence  Facilitate creative ways to overcome individuals’ challenges  Assist in cultivating and maintaining older adults’ cognitive state and mental health CHECK FOR UNDERSTANDING (15 minutes) The instructor will instruct the students to answer the ten (10) questions and write the rationale for each question. One (1) point will be given to correct answer and another one (1) point for the correct ratio. They are given 15 minutes for this activity. Multiple Choice (For 1-10 items, please refer to the questions in the Guided / Rationalization Activity) RATIONALIZATION ACTIVITY (10 minutes) The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss among themselves. 1. Nurse Bianca is aware that the theory of aging most likely to explain why the older population is at risk for autoimmune disorder is known as: a. cross-link theory. b. free radical theory. c. error theory. d. autoimmune theory. Answer: D. Autoimmune theory Rationale: The immunity theory proposes that cellular errors in the immune system have been found to lead to an auto- aggressive phenomenon in which normal cells are misidentified as alien and are destroyed by the body's own immune system. This phenomenon is used to explain the increase of autoimmune disorders as we age. The cross-link theory describes aging in terms of the accumulation of errors of cross-linking or stiffening of proteins in the body. The free radical This document and the information thereon is the property of PHINMA Education (Department of Nursing) 4 of 7 theory describes free radical errors as the result of random damage from free radicals. The error theory is a group of theories that propose that aging is an accumulation of errors in the synthesis of cellular DNA and RNA, which are the building blocks of the cell. 2. The family member of a patient asks if vitamin C will prevent aging. In formulating an appropriate response, the nurse considers what theory? a. free radical theory. b. autoimmune theory. c. wear-and-tear theory. d. continuity theory. Answer: A. Free radical theory Rationale: The free radical theory posits that aging is a result of random damage from free radicals. Research is ongoing on the ability of substances with antioxidant effects to counter the actions of free radicals. For many years it was thought that consumption of supplemental antioxidants, such as vitamin C, could delay or minimize the effects of aging. However, it is now known that the intake of supplemental antioxidants can be deleterious to one's health. The autoimmune theory posits that the cells of the immune system become progressively more diversified with age and lose self-regulatory ability. The use of vitamin C is not associated with this theory. The wear-and-tear theory posits that cellular errors are the result of wearing out over time due to constant use. The continuity theory is a sociological theory that deals with the tendency of individuals to develop and maintain consistent patterns of behavior throughout their lives. 3. Nurse Maria implements the concepts of the activity theory of aging when instructing the older client with osteoarthritis to: a. continue her daily walking routine. b. curtail further increases in physical activity. c. document preferred end-of-life interventions. d. avoid exposing herself to crowds. Answer: A. Continue her daily walking routine. The activity theory states that successful aging equals active aging, which is related to the person's need to maintain a productive life for it to be a happy life. Curtailing increases in physical activity is diametrically opposite to continuing a daily walking routine and contrary to the tenets of the activity theory. End-of-life decisions and avoiding exposure to crowds are not related to the activity theory since they do not directly affect the productiveness of a client's life. 4. The 45-year-old patient reports to the nurse he feels he is going through a "mid-life crisis." The nurse recognizes this phenomenon refers to the theory developed by which psychologist? a. Jung b. Erikson c. Newman d. Havighurst Answer: A. Jung Carl Jung's theory of development proposes that an individual progresses through life searching and setting goals for him or herself in an ongoing search for one's "true self." The "mid-life crisis" is the time in which the individual reevaluates his or her life and progresses toward his or her true self. The theories of Erikson, Newman, and Havighurst do not include a mid-life crisis. 5. The patient in the clinic tells the nurse she can "feel her biologic clock ticking." The nurse knows the patient views aging based on which theory? a. Gene theory b. Programmed theory c. Rate of living theory d. Somatic mutation theory Answer: B. Programmed theory Rationale: The programmed theory proposes that, at conception, a "biologic clock" begins ticking that determines the number of cell divisions that occur before death. The rate of living theory postulates each person has a finite This document and the information thereon is the property of PHINMA Education (Department of Nursing) 5 of 7  number of heart beats. The gene theory discusses aging from the perspective of one or more harmful genes that are activated over time and bring about age-related changes. The somatic mutation proposes that aging is caused by environmental damage to DNA. 6. An 80-year-old female who enjoys good health explains to her primary provider that she attributed her health status to her regular intake of berries, fruit, green tea, which she states “help cleanse the damaging molecules out of my body.”Which of the following theories of aging underlies the client’s health behaviors? a. Free radical theory b. Biogerontology c. Disposable soma theory d. Cross-linking theory Answer: A. Free Radical theory Rationale: The free radical theory of aging attributes damage to the accumulation of free radicals that may countered by the intake of antioxidants. This is not an explicit component of the disposable soma or cross-linking theory of aging. Biogerontology is the study of the relationship between aging and disease. 7. The nurse would recognize successful aging according to Jung’s theory when a long-term care facility resident demonstrates which of the following behaviors? a. The resident takes special care to dress for dinner in a manner that pleases his tablemates. b. The resident asks permission to sit on the patio with other residents. c. The resident asks persons in his hall if his television is bothering them. d. The resident wears a large cowboy hat at all times because he likes it. Answer: D.The resident wears a large cowboy hat at all times because he likes it. Rationale: Successful aging, according to Jung, includes acceptance and valuing of the self without regard to the view of others. 8. The nurse in the long term care facility who cares for primarily order adults knows these adults are in which stage of Erikson’s developmental tasks? a. Trust vs mistrust b. Integrity vs Despair c. Industry vs Inferiority d. Generativity vs stagnation Answer: B.Integrity vs Despair Rationale: The developmental stage for the older adult is integrity versus despair, where the individual looks back on his or her life with pride that he or she had a positive impact or despair that his or her impact or despair that his or her impact was negative. Trust versus mistrust, integrity versus despair , and industry versus inferiority are stages for younger individuals. 9. Which theory suggests that older people who have low levels of social activity have a high degree of life satisfaction? a. Activity b. Age stratification c. Disengagement d. Exchange Answer: C. Disengagement Rationale: Disengagement theory suggests that it is natural for people who are older to gradually withdraw from society and for society to withdraw from people who are older. Since this is an expectation on both sides, the person whose life activities decrease perceives this as a normal and a positive situation, and therefore, experiences high degree of satisfaction. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 6 of 7 10. Based on the free theory of aging, what would be an appropriate behavior that might increase one’s life expectancy? a. Exercise for 45 minutes at least three times a week. b. Eat food rich in antioxidants. c. Eat a low-calorie, high protein diet. d. Do nothing. Life expectancy is determined through genetic programming. Answer: B. Eat food rich in antioxidants. Rationale: Antioxidants will reduce the number and activity of the free radicals and may have an impact of life expectancy. LESSON WRAP-UP (5 minutes) Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track how much work they have accomplished and how much work there is left to do. This tracker will be part of the student activity sheet. You are done with the session! Let’s track your progress. AL Strategy: CAT 3-2-1 This strategy provides a structure for students to record their own comprehension and summarize their learning. It also gives teachers opportunity to identify areas that need re-teaching, and areas of student interest. 3-2-1 Three things you learned: 1) _____________________________________________________________________________________________ 2) _____________________________________________________________________________________________ 3) _____________________________________________________________________________________________ Two things that you’d like to learn more about: 1) _____________________________________________________________________________________________ 2) _____________________________________________________________________________________________ One question you still have: 1) _____________________________________________________________________________________________ (For Related Learning Experience, please refer to your clinical instructor.) This document and the information thereon is the property of PHINMA Education (Department of Nursing) 7 of 7  Care of Older Adult INSTRUCTOR’S GUIDE BS NURSING / THIRD YEAR Session # 4 LESSON TITLE: MEDICATIONS OF OLDER ADULTS Materials: LEARNING OUTCOMES: Book, pen and notebook Upon completion of this lesson, the nursing student can: 1. Demonstrate the nurse’s role in the older adult’s adherence to a medication regimen. References: 2. Apply knowledge on age-related physiological changes concepts. Mauk, K. L. (2018). Gerontological Nursing: Competencies for Care (4th ed.). Jones & Bartlett 3. Provide safe, appropriate and holistic care to older adult. Learning. LESSON PREVIEW/REVIEW (5 minutes) The instructor should summarize the previous topic. Explain the Hook Activity. The instructor will let the students list down the 10 rights of drug administration. 1. Right Patient 6. Right Documentation 2. Right Medication 7. Right Client Education 3. Right Dosage 8. Right to Refuse 4. Right Route 9. Right Assessment 5. Right Time 10. Right Evaluation MAIN LESSON (25 minutes) Review the 10 rights of medications The instructor should discuss the following topics. Instruct students to take down notes. Medications of Older Adults A. The Effects of Aging on Drugs Normal aging is associated with certain physiological changes that can significantly influence drug response. Both pharmacokinetics and pharmacodynamics play a role in how a person will respond to a drug. 1. Pharmacokinetics  Absorption - the rate of drug movement through the body may decrease with age, the extent of drug absorption is least affected by age.  Distribution- As patients age, total body water declines and fat stores increase. This physiological change affects the distribution phase of highly water-soluble and fat-soluble drugs. Therefore, the volume of distribution may be decreased for drugs that are highly water soluble and increased for drugs that are highly lipid soluble. 2. Pharmacodynamics - The effects of similar drug concentrations at the site of action may be greater or less than those in younger patients. Therefore, the potential for increased sensitivity to medications at the cellular level must be considered when administering them to an elderly patient. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 1 of 6  3. Adverse Drug Reactions Older patients, with multiple disease states, often consume many different medications to treat both acute and chronic medical conditions. As a result, ADRs occur often in older patients. Age-related alterations in drug distribution, hepatic metabolism, and renal clearance all play a significant role in the chances of an elderly patient developing an ADR. ADRs in elderly patients may decrease functional status, increase health services use, and in some rare cases have resulted in death. Overall, ADRs represent a major problem for elderly patients. In addition to better prescribing patterns from the physicians, there’s a need for nurses and pharmacists to increase medication monitoring. B. Polypharmacy Many older patients are prescribed multiple drugs, take over-the-counter medications, and are often prescribed additional drugs to treat the side effects of the medications that they are already taking. The increase in the number of medications often leads to polypharmacy, which is defined as the prescription, administration, or use of more medications than are clinically indicated in a given patient. Potential adverse outcomes of polypharmacy include adverse drug reactions, increased cost, and noncompliance. Reasons for polypharmacy: a. Lack of communication among multiple health-care providers. b. Lack of information about over-the-counter drug use. c. Lack of information about client noncompliance. d. Use of complementary (alternative, folk medicine) therapies and fear of telling health-care provider. e. Assumption that, once medication is started, it should be continued indefinitely and not changed. f. Assumption that, if there are no early side effects, there will not be any later. g. Changes in daily habits (smoking, activity, diet/fluid intake). h. Changes in mental-emotional status that may affect consumption patterns. i. Changes in health status. j. Financial limitations (drug substitution). Several interventions that may help the prescriber to prevent polypharmacy:  Knowing all medications, by both brand and generic name, being used by the patient;  Identifying indications for each medication;  Knowing the side effect profiles of the medications;  Eliminating drugs with no benefit or indication;  Avoiding the urge to treat a drug reaction with another drug. C. Inappropriate Prescribing Overall there is no generalized rule for prescribing drugs to the geriatric population. There are numerous studies that indicate that some prescribing patterns in the elderly population are inappropriate, such as no indications for use of a drug, inappropriate frequency of medications, inadequate dosages, and the possibility of drug interactions or ADRs QUESTIONS TO ASK TO AVOID INAPPROPRIATE PRESCRIBING FOR ELDERLY PATIENTS 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? This document and the information thereon is the property of PHINMA Education (Department of Nursing) 2 of 6 D. Compliance Although age alone does not affect compliance, about 40% of elderly persons do not adhere to their medication regimen. The more complex the medication regimen, the less likely the patient will comply. For elderly patients, nonadherence may result from the patient trying to avoid side effects and therefore reduce the amount of drug consumed, lack of money, or forgetfulness (early dementia). Seniors may simply not be taking the medications they need because they cannot afford them. Compliance can be encouraged by establishing a good relationship with the patient, providing education about possible side effects, providing clear instructions for how the medication should be taken, encouraging questions from the patient, and providing home nursing support as needed. Pharmacotherapy in older Adult General Information  Decreased body weight, dehydration, alteration in fat to muscle ratio, slow organ functioning may cause accumulation of the drugs in the body due to higher concentration in the tissues and slowed metabolism and excretion of the drug  Multiple chronic disease affecting older adults may also causes changes in the metabolism and excretion of medications.  Medication errors among adult community-dwelling adults are estimated to be 25-50%.  Drug-drug interactions are increased secondary to older adult often having more than one prescribing health care provider. Nursing Care  Conduct a “brown bag” evaluation to assess all prescription , over-the-counter, herbal medications the client may be taking  Assess the clients understanding of the reasons for the drug therapy  Assess the client’s vision, memory, and judgement. Reading level, level dexterity and motivation to determine ability to self-medicate  Provide instructions in large print premeasured syringes, memory aid and daily drug does containers to enhance self-medicating abilities  Check with the pharmacist for any drug-drug interactions if unsure  Before beginning a medication, obtain baseline vital signs, mental status , vision, and bowe/bladder function  Drug-induced side effects may present as confusion, incontinence , falls, or immobility  Assess the client’s ability to pay for the prescription;  If the client requires assistance in taking medications, teach family members. Proper techniques for administering oral medication include: position head forward with neck slightly flexed to facilitate swallowing and avoid risk of aspiration.  If client has swallowing difficulties, obtain liquid form of oral medications wherever possible.  Assess client for effectiveness of medications and any adverse reactions. CHECK FOR UNDERSTANDING (15 minutes) Multiple Choice (For 1-10 items, please refer to the questions in the Rationalization Activity) RATIONALIZATION ACTIVITY (10 minutes) The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss among themselves. 1. Which is the best example of polypharmacy? a. Your patient is filling her medications at more than 1 drugstore. b. Your patient is taking more than 2 medications. c. Your patient is taking more than 9 medications. d. Your patient is taking a potentially inappropriate combination of medicines. Answer:D. Your patient is taking a potentially inappropriate combination of medicines. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 3 of 6 Rationale: Polypharmacy refers to a potentially inappropriate combination of medications. While it is true that a higher number of medications puts patients at risk of polypharmacy, it is not in and of itself indicative of polypharmacy. 2. Which is the most effective method of managing polypharmacy? a. Review of medications at each office visit, to ensure an accurate med list. b. Limit your patients’ medication list to no more than 4 medicines. c. Regularly assess patient adherence to the medication regimen. d. (a) and (c) Answer:D. Both A and C Rationale: Reviewing the list of medications and assessing their adherence to medications are both effective methods to prevent polypharmacy. 3. Oral drugs may be absorbed less quickly in older people because: a. Of increased number of receptors in the heart b. Of increased liver metabolism c. Of increased kidney function d. Of decreased gastrointestinal motility Answer: D. Of decreased gastrointestinal motility Rationale: Drug absorption is theoretically reduced in the older patient due to loss of mucosal intestinal surface, decrease in gastrointestinal blood flow and reduced gastric acidity. 4. Enteric coated tablets are designed to avoid being dissolved in the highly acidic stomach. Instead, they dissolve in the intestine. Knowing this and what you know about gastrointestinal changes associated with age, what can you conclude about enteric coated tablets and older patients? a. The tablets will need to be given intravenously instead b. These tablets will probably dissolve more slowly c. The enteric coated tablets are unaffected by changes associated with age d. These tablets may dissolve more quickly Answer: B. These tablets will probably dissolve more slowly Rationale: Drug dissolution is effected by the aging of the gastrointestinal mucosa in the elderly and the decrease of gastric acid secretion (25% - 20% reduction). However, due to the weakening of gastrointestinal movement in the elderly and slow gastric emptying rate, drugs stay longer in the gastrointestinal tract, which is conducive to greater drug absorption. The combination of these negative and positive factors usually results in normal drug absorption rate. 5. In an older population we can expect that drugs will be: a. Absorbed more quickly b. Metabolized more quickly c. Excreted more rapidly by the kidneys d. Excreted less readily Answer: D. Excreted less readily Rationale: The kidneys remove substances from the blood and eliminate them in the urine. The total size of the kidneys decrease with age, as does the number of functioning nephrons. There is also decreased renal blood flow with increasing age. This will result in a progressive decrease in renal function as demonstrated by measures of the glomerular filtration rate (GFR). 6. Which of the following is an age-related physiologic change that may affect the absorption of drugs? a. Xerostomia b. Faster stomach emptying c. Altered pH of the stomach contents d. Increased gastrointestinal tract motility Answer: C. Altered pH of the stomach contents Rationale: The stomach can produce less acid as a result of aging. According to a 2013 review, hypochlorhydria is the main change in the stomach of older adults. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 4 of 6 7. The nurse is caring for a group of older adult patients who are all receiving multiple medications. The nurse understands that it is essential to individualize each patient's therapy. Which is the best rationale for this practice? A. The percentage of drug absorbed often is decreased in older adults. B. Most older adults have decreased body fat and increased lean mass. C. Hepatic metabolism tends to increase in older adults, resulting in decreased drug levels. D. Renal function declines with age, leading to decreased drug excretion. Answer: D. Renal function declines with age, leading to decreased drug excretion. Rationale: Renal function declines in older adults, leading to decreased excretion and potential drug accumulation. Although absorption may be delayed in older adults, the percentage absorbed does not change. Most older adult patients have increased body fat and decreased lean mass. Hepatic metabolism tends to decline with age. 8. When assessing for drug effects in the older adult, which phase of pharmacokinetics is the greatest concern? A. Absorption B. Distribution C. Metabolism D. Excretion Answer: D. Excretion Rationale: Although pharmacokinetic changes in older adults affect all phases of kinetics, drug accumulation secondary to reduced renal excretion is the most important cause of ADRs in the older adult. 9. All of the following are impacts of polypharmacy EXCEPT: a. Increased communication between care teams b. Adverse drug events c. Increased healthcare costs d. Medication non-adherence Answer: A. Increased communication between care teams Rationale: Lack of communication among multiple health-care providers is one of the reasons for polypharmacy. 10. The single most important thing we can do as healthcare providers to prevent polypharmacy is: a. Encourage our patients to carry a list of home medications in their wallet b. Tell our patient to appoint a lead doctor c. Educate our patients on each of their new medications d. Tell our patients to Google all of their medications Answer: C. Educate our patients on each of their new medications Rationale: One of the roles of a nurse is to educate the patient regarding his/her medications. By educating patients regarding his/her medications promote compliance and prevent further problems. LESSON WRAP-UP (5 minutes) Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track how much work they have accomplished and how much work there is left to do. This tracker will be part of the student activity sheet. You are done with the session! Let’s track your progress. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 5 of 6 AL Strategy: Outcome Sentences The instructor will let the students reflect on the discussion and see what they can get out of it. Instruct them to complete the sentences below. 1. I learned… 2. I was surprises… 3. I’m beginning to wonder… 4. I feel… 5. I promise… (For Related Learning Experience, please refer to your clinical instructor.) This document and the information thereon is the property of PHINMA Education (Department of Nursing) 6 of 6  Care of Older Adult INSTRUCTOR’S GUIDE BS NURSING / THIRD YEAR Session # 5 LESSON TITLE: ETHICAL/LEGAL PRINCIPLES AND ISSUES Materials: Book, pen and notebook LEARNING OUTCOMES: References: Upon completion of this lesson, the nursing student can: Mauk, K. L. (2018). Gerontological Nursing: 1. Adhere to ethico-legal considerations when providing safe Competencies for Care (4th ed.). Jones & Bartlett care and quality nursing care of older adults. Learning. 2. Apply ethical reasoning and decision-making process to Republic Act No. 9994: GOVPH. (2010, February address situations of ethical distress and moral dilemma. 15). Retrieved July 25, 2020, from https://www.officialgazette.gov.ph/2010/02/15/rep 3. Demonstrate strategies for facilitating appropriate levels of ublic-act-no-9994/ autonomy and decision making in the care of geriatric patients. LESSON PREVIEW/REVIEW (5 minutes) The instructor should summarize the previous topic. Explain the Hook Activity. Case Study: Instruct the students to read and answer the following questions. Chest physiotherapy is prescribed for an elderly cancer patient by the attending doctor, but he refuses. Must the physiotherapist insist on carrying out the treatment plan? Is it unethical to go against patient’s wish to refuse? MAIN LESSON (25 minutes) The instructor should discuss the following topics. Instruct students to take down notes. Nursing: Scope and Standards of Practice Standards are authoritative statement by which the nursing profession describes the responsibility for which its practitioners are accountable. It reflects the values and priorities of the profession. SEC. 28. Scope of Nursing. — A person shall be deemed to be practicing nursing within the meaning of this Act when he/she singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting. It includes, but not limited to, nursing care during conception, labor, delivery, infancy, childhood, toddler, pre-school, school age, adolescence, adulthood and old age. As independent practitioners, nurses are primarily responsible for the promotion of health and prevention of illness. As members of the health team, nurses shall collaborate with other health care providers for the curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering, and when recovery is not possible, towards a peaceful death. It shall be the duty of the nurse to: (a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to, traditional and innovative approaches, therapeutic use of self, executing health care techniques and procedures, essential primary health care, comfort measures, health teachings, and administration of written prescription for treatment, therapies, oral, topical and parenteral medications, internal examination during labor in the absence of antenatal bleeding and delivery. In case of suturing of perineal laceration, special training shall be provided according to protocol established; (b) Establish linkages with community resources and coordination with the health team; This document and the information thereon is the property of PHINMA Education (Department of Nursing) 1 of 8 (c) Provide health education to individuals, families and communities; (d) Teach, guide and supervise students in nursing education programs including the administration of nursing services in varied settings such as hospitals and clinics; undertake consultation services; engage in such activities that require the utilization of knowledge and decision-making skills of a registered nurse; and (e) Undertake nursing and health human resource development training and research, which shall include, but not limited to, the development of advance nursing practice; Provided, That this section shall not apply to nursing students who perform nursing functions under the direct supervision of a qualified faculty: Provided, further, That in the practice of nursing in all settings, the nurse is duty- bound to observe the Code of Ethics for nurses and uphold the standards of safe nursing practice. The nurse is required to maintain competence by continual learning through continuing professional education to be provided by the accredited professional organization or any recognized professional nursing organization: Provided, finally, That the program and activity for the continuing professional education shall be submitted to and approved by the Board. Republic Act 7432 AN ACT TO MAXIMIZE THE CONTRIBUTION OF SENIOR CITIZENS TO NATION BUILDING, GRANT BENEFITS AND SPECIAL PRIVILEGES AND FOR OTHER PURPOSES. Section 4: Privileges for the Senior Citizens. The senior citizens shall be entitled to the following: 1. The grant of twenty percent (20%) discount from all establishments relative to utilization of transportation services, hotels and similar lodging establishment, restaurants and recreation centers and purchase of medicines anywhere in the country: Provided, That private establishments may claim the cost as tax credit; 2. A minimum of twenty percent (20%) discount on admission fees charged by theaters, cinema houses and concert halls, circuses, carnivals and other similar places of culture, leisure, and amusements; 3. Exemption from the payment of individual income taxes: Provided, That their annual taxable income does not exceed the poverty level as determined by the National Economic and Development Authority (NEDA) for that year; 4. Exemption from training fees for socioeconomic programs undertaken by the OSCA as part of its work; e) e) Free medical and dental services in government establishment anywhere in the country, subject to guidelines to be issued by the Department of Health, the Government Service Insurance System and the Social Security System; 5. To the extent practicable and feasible, the continuance of the same benefits and privileges given by the Government Service Insurance System (GSIS), Social Security System (SSS) and PAG-IBIG, as the case may be, as are enjoyed by those in actual service. REPUBLIC ACT NO. 9257, OTHERWISE KNOWN AS THE “EXPANDED SENIOR CITIZENS ACT OF 2003” WHEREAS, the President signed into law on February 26, 2004 Republic Act No. 9257, known as An Act Granting Additional Benefits and Privileges to Senior Citizens Amending for the Purpose Republic Act No. 7432, Otherwise known as “An Act To Maximize The Contribution of Senior Citizens to Nation Building, Grant Benefits And Special Privileges And For Other Purposes” ; REPUBLIC ACT NO. 9994 AN ACT GRANTING ADDITIONAL BENEFITS AND PRIVILEGES TO SENIOR CITIZENS, FURTHER AMENDING REPUBLIC ACT NO. 7432, AS AMENDED, OTHERWISE KNOWN AS “AN ACT TO MAXIMIZE THE CONTRIBUTION OF SENIOR CITIZENS TO NATION BUILDING, GRANT BENEFITS AND SPECIAL PRIVILEGES AND FOR OTHER PURPOSES” SEC. 5. Government Assistance. – The government shall provide the following: “(a) Employment This document and the information thereon is the property of PHINMA Education (Department of Nursing) 2 of 8 “Senior citizens who have the capacity and desire to work, or be re-employed, shall be provided information and matching services to enable them to be productive members of society. Terms of employment shall conform with the provisions of the Labor Code, as amended, and other laws, rules and regulations. Ethical Principles The gerontologic nurse follows all ethical principles in the roles of clinician, advocate, case manager, researcher, and administrator. Basic ethical principles include: Patient Rights Patient rights direct actions on ethical issues in the care of geriatric populations. Rights are considered basic to human life, and each person is entitled to them on a legal, moral, or ethical basis (Ellis & Hartley, 2004).  Advance Directives and Living Wills o Advance directives describe actions to be taken in a situation where the patient is no longer able to provide informed consent. o Living wills are alternative documents that direct preferences for end-of life care issues providing an “if... then... ” plan. They often include what type of care to provide and whether resuscitation measures should be taken.  Durable Power of Attorney o A living will may include a durable power of attorney, a legal document designating an alternative decision maker in the event that the person is incapacitated. This document supersedes all other general legal designations for decision makers.  PATIENT’S BILL OF RIGHTS 1. Right to Appropriate Every person has a right to health and medical care corresponding to his state of Medical Care and health, without any discrimination and within the limits of the resources, manpower Humane Treatment and competence available for health and medical care at the relevant time. 2. Right to Informed The patient has a right to a clear, truthful Consent. and substantial explanation, in a manner and language understandable to the patient, of all proposed procedures, whether diagnostic, preventive, curative, rehabilitative or therapeutic. 3. Right to Privacy and The privacy of the patients must be assured at all stages of his treatment. Confidentiality 4. Right to Information In the course of his/her treatment and hospital care, the patient or his/her legal guardian has a right to be informed of the result of the evaluation of the nature and extent of his/her disease, any other additional or further contemplated medical treatment on surgical procedure or procedures, including any other additional medicines to be administered and their generic counterpart including the possible complications and other pertinent facts, statistics or studies, regarding his/her illness, any change in the plan of care before the This document and the information thereon is the property of PHINMA Education (Department of Nursing) 3 of 8  change is made, and the person's participation in the plan of care and necessary changes before its implementation. 5. The Right to The patient is free to choose the health care provider to serve him as well as the Choose Health Care facility except when he is under the care of a service facility or when public health Provider and Facility and safety so demands or when the patient expressly waives this right in writing. 6. Right to Self- The patient has the right to avail himself/herself of any recommended diagnostic and Determination treatment procedures. 7. Right to Religious The patient has the right to refuse medical treatment or procedures which may be Belief contrary to his religious beliefs, subject to the limitations described in the preceding subsection 8. Right to Medical The patient is entitled to a summary of his medical history and condition. Records 9. Right to Leave The patient has the right to leave hospital or any other health care institution regardless of his physical condition. 10. Right to Refuse The patient has the right to be advised if the health care provider plans to involve him Participation In Medical in medical research, including but not limited to human experimentation which may Research be performed only with the written informed consent of the patient. 11. Right to The patient has the right to communicate with relatives and other persons and to Correspondence and to receive visitors subject to reasonable limits prescribed by the rules and regulations of Receive Visitors the health care institution. 12. Right to Express The patient has the right to express complaints and grievances about the care and Grievances services received without fear of discrimination or reprisal and to know about the disposition of such complaints. 13. Right to be Informed Every person has the right to be informed of his rights and obligations as a patient. of His Rights and Obligations as a Patient Ethics in Practice Ethical dilemmas and conflicts surround us in real life, and ethical principles alone are not likely to address many of the quandaries and dilemmas occurring in the care of geriatric patients.  Mistakes Considerable effort has been put into reducing mistakes and improving patient safety. However, even the most conscientious nurse will make a mistake or two. Responding to mistakes is intimidating, embarrassing, and risky for most. Ethical responses to mistakes include: 1. Honestly admitting the error occurred in a neutral and objective manner 2. Taking proper steps to correct the situation 3. Apologizing for the mistake 4. Making amends as possible 5. Evaluating how to prevent such mistakes in the future  Conflict of Interest Conflict of interest situations arise from competing loyalties and opportunities. This may include: 1. conflicts of values between the nurse’s value system and choices made by the patients, their families, other health care team members, the organization, or the insurance company. 2. discussions related to resource allocation and end-of-life care. 3. occur when incentive systems or other financial gains create conflict between professional integrity and self-interest. This document and the information thereon is the property of PHINMA Education (Department of Nursing) 4 of 8 CHECK FOR UNDERSTANDING (15 minutes) Multiple Choice (For 1-10 items, please refer to the questions in the Guided / Rationalization Activity) RATIONALIZATION ACTIVITY (10 minutes) The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss among themselves. 1. You are caring for a client at the end of life. The client tells you that they are grateful for having considered and decided upon some end of life decisions and the appointments of those who they wish to make decisions for them when they are no longer able to do so. During t