Care Across The Continuum Fall 2022 Past Paper PDF

Care Across the Continuum H&H II – Week 5 Copyright Statement This presentation and all its content is copyright and is owned by Durham College or its Licensors (2022). © 2022 - Durham College Learning Objectives After completing this module, you will b...

Care Across the Continuum H&H II – Week 5 Copyright Statement This presentation and all its content is copyright and is owned by Durham College or its Licensors (2022). © 2022 - Durham College Learning Objectives After completing this module, you will be able to demonstrate the following: 1.Describe the concept of Care Across the Continuum and the range of living situations and care giving options available as an adult ages 2.Describe common physical & psychological concerns when hospitalized 3.Describe the care needs of the hospitalized older adult and associated interventions 4.Discuss Caregiving and Caregiver stress 5.Identify similarities and differences between Dementia, Delirium and © 2022 - Durham College Depression Care Across the Continuum H&H II – Week 5.2 Care Across the Continuum Aging in Place – remain in home as long as possible Decisions to change residence is very difficult + Decisions are based on health status and care needs Residential Options include: Partial Complete Independe Dependenc Dependenc nt e e © 2022 - Durham College Care Across the Continuum The majority of older adults prefer to "age in place", meaning they would like to remain in their homes, living independently for as long as possible. However, there may come a time where an older adult develops complex health needs and may require care in a variety of different settings as they age. This decision will be based on changes to their health status and care needs. The Continuum of residential options ranges from Independence to Partial Dependence to Complete Dependence. Residential Options © 2022 - Durham College Residential Options Some older adults may move from independent living right into a LTC facility after a serious fall or stroke, as their care needs will increase dramatically. Others may gradually transition across the continuum, between home, to a retirement home to a LTC facility. Some older adults may be able to age in place permanently if they have the right care resources available to them. Independent Living Options Independent living options  Home ownership (aging in place)  Social housing  Life lease  Adult style communities  Shared housing WHO: Elements of Aging  Cohabitation Friendly Cities & Communities © 2022 - Durham College Supportive Living Options Supportive Housing – buildings designated for older adults + Include basic PSW & Nursing care services + Includes social support and recreational events Assisted Living / Retirement Homes – bedrooms within a facility + Provides health and social support programs + Designed for older adults who require extra support © 2022 - Durham College Health Care Facility Options Long Term Care Homes – 24 hour specialized care for older adults who are no longer able to perform ADLs 46% of LTC’s are publicly owned 54% of LTC’s are privately owned Residents live in LTC homes – this is their home MOHLTC - Residents Bill of Rights – Box 28.6 © 2022 - Durham College Long Term Care Move from institution-focused approach to a resident-focused approach Culture change from one that fosters dependence to empowering residents that is focused on person- centred care Review Box 28.7 – Institution-Centred vs. Person- Centred Culture © 2022 - Durham College Long Term Care Long term care settings are in the process of revitalization, recognizing that they need to change from an institution-focused approach to a resident- focused approach. This means changing the culture of LTC's from one that fosters dependence to an empowering model that focuses on person-centred care. Person-centred care maximizing independence and autonomy in decision making and provides a sense of control for older adults. When LTC's provide person-centred care, residents make decisions for themselves such as when to get up, bathe, eat, and go to bed. They are treated as individuals with preferences as opposed to those individuals needing to comply with institutional routines and practices. Please review the Box 26-6 on the right on the key differences between institution-centred care and person-centred cultures. Transitions Care transitions – occur as an older adult moves from one health care provider or setting to another Transitions require a number of clinical and communication activities Transitions include multiple complex changes that can create gaps in care © 2022 - Durham College Transitions Older adults have complex health care needs and often require care in multiple settings across the continuum of care. “Care transition” refers to the movement of care receivers from one health care practitioner or setting to another as their condition and care needs change. Transitions “Successful care transitions require multi-disciplinary communication and coordination, comprehensive planning, including patient/caregiver education and clinician involvement, and shared accountability during all points of transition. When gaps occur in care transitions, individuals are susceptible to fragmentation in care, poor quality of care, unfavourable experiences, compromised patient safety, and adverse medical events.” (Canadian Institutes of Health Research, 2020, in Boscart et al., 2023, p. 453). © 2022 - Durham College Transitions Transitions happen frequently Older adults at high risk include: + Multiple medical conditions + Mental health conditions + Isolated individuals + Non-English speakers + Immigrants + Older adults on low incomes © 2022 - Durham College Nursing Implications Nurses minimize the gaps in care that are present during this critical transition Strategies to minimize risk + Minimize the number of transfers from unit to unit + Consistent nursing care + Strict adherence to med rec and med management + Family / caregiver education, orientation and discharge + Timely communication between the IP Team and sites of service © 2022 - Durham College Nursing Implications The role of nursing is critical when easing the transition for older adults as well as in managing the gaps in care that are prevalent during this critical time. There are several strategies that help minimize the risk to older adults as they move from one care provider or setting to another. Some of these strategies include, minimizing the number of transfers from unit to unit, consistent nursing care, strict adherence to medication reconciliation and medication management, providing family / caregiver education and orientation programs, comprehensive discharge planning, and thorough and timely communication amongst interprofessional team members and sites of services. Please see below a comprehensive list of key services that should be included when transitioning an individual across the continuum of care (Box 26-8). Trends & Issues in LTC H&H II – Week 5.3 Facts & Figures © 2022 - Durham College  Key statistics to pay attention to is the number of older adults waiting for placement in a LTC in Ontario. As of 2020, that number is 35,308. In addition, it will take on average 152 days for an older adult to be placed in a LTC. This places a significant burden on other sectors of the health care system or families who will need to provide care for the older adult while they wait for placement in an LTC. Many of these patients will end up being hospitalized while they wait for placement, adding to the "hallway medicine" crisis currently facing the province. In addition, over the next 30 years or so, the older adult population is expected to double. Therefore, Ontario needs to build capacity now in order to meet the ongoing health care needs of this population as it continues to grow. Older adults in or seeking a placement in LTC settings have a variety of complex medical conditions or cognitive concerns that put them at high risk in the community. Many of these older adults will experience a health related emergency at home, be admitted to hospital and wait in an Alternate Level of Care facility, while they wait for a LTC placement. Facts & Figures © 2022 - Durham College Trends & Issues in LTC LTC is regulated by the province of Ontario If LTCs are not staffed properly, care of older adults that are frail and / or seriously ill results in: + Staff that experience intense labour, high workloads, stressful work environments & burnout + Compromise patient safety + Family satisfaction + Increase negative patient care outcomes This leads to both staff and the public holding negative views of the LTC sector © 2022 - Durham College LTC Long Term Care homes are regulated in the province of Ontario, with laws, regulations and standards varying across the province. The Long Term Care sector includes nursing homes, specialized care homes and personal care homes. Most people who enter an LTC environment do so as they require assistance to perform activities of daily living that they can no longer perform independently. This may be due to a number of factors, such as mobility issues, cognitive impairment and environmental concerns at home etc... If not staffed properly, care of older adults that are frail and / or seriously ill results in staff that experience intense labour, high workloads, stressful work environments and burnout. Furthermore, it can compromise patient safety, family satisfaction and patient care outcomes. This leads to both staff and the public holding negative views of the LTC sector. COVID in LTC The LTC sector was severely affected by COVID Staff and residents were significantly affected Canadian Armed Forces (CAF) called in to support CAF Report was written to highlight the conditions of certain LTC homes where they were assisting. + "Operation Laser - Joint Task Force Central Observations in LTC Facilities in Ontario". © 2022 - Durham College  The virus spread quickly through some LTC facilities, infecting many residents and health care staff. During the height of the crisis, the Canadian Armed Forces (CAF) were called in to support LTC facilities that were hit the hardest. As they provided support to the teams working in these facilities, they found significant gaps and deficiencies in the care provided, and wrote a report detailing their concerns. The CAF Report was written to highlight the conditions of certain LTC homes where they were assisting. The CAF report is known as "Operation Laser - Joint Task Force Central Observations in LTC Facilities in Ontario". This report was made public in May of 2020. A summary of key concerns is available in the RNAO Call to Action response issued days after the CAF report was released. These concerns included: RNAO Response to CAF Reprt © 2022 - Durham College CAF Report Please note that the CAF report is not indicative of all LTC homes and these conditions do not exist everywhere. However it did raise concerns about the LTC system overall. Many organizations, including the Registered Nurses Association of Ontario (RNAO) have since advocated for issues in the LTC system to be addressed. The COVID crisis has provided an opportunity to highlight gaps in care and services delivered to our older adult population. The question now, is what will we do with this information, and how will it impact the LTC system in the future. Acute Care Hospitalization H&H II – Week 5.4 Hospitalization Hospitalization can cause many challenges for OA Hospitalization may impact: + Quality of life + Decline in independence + Decline in functionality + Loss of mobility + Loss of ability to perform ADL’s independently © 2022 - Durham College Hospitalization Statistics show that 80% of patients admitted to acute care units lost mobility independence during their hospital stay, and 33% of older adults greater than 75 years lost their ability to perform ADL's independently. Once discharged only half of patient regained their ability to perform ADL's after 3 months. Age related changes and chronic conditions, coupled with an acute care hospital stay increases the risk for older adults. Due to hospital system pressures, many older adults are getting discharged sooner then they are ready, leading to further complications and functional decline when they return home. Consequences of Hospitalization Deconditioning is the loss of muscle tone and endurance. This can occur as a result of becoming sedentary, debilitation from disease or prolonged bed rest. Frailty is the condition of being weak or delicate. This is often associated with sarcopenia, the loss of muscle mass, strength and function. Failure to Thrive (FTT) is a state of decline in older adults. Failure to thrive occurs when the patient undergoes a process of functional decline, progressive apathy and a loss of willingness to eat and / or drink. Delirium is defined as an acute state of confusion that is often caused © 2022 - Durham College Minimizing Risks Specialized care is required to minimize risk for deterioration Paying attention to the risks of hospitalization can meet patients needs for comfort, safety, nutrition and skin integrity Nursing interventions can minimize risks + Complete a thorough orientation to unit + Answer patient & family questions + Identify ways to call for help + Complete a thorough history & physical assessment + Obtain baseline ADL assessment © 2022 - Durham College Minimizing Risks When older adults are admitted to the hospital, it is important that the nurses pays attention to orienting them to the unit as well as completes a comprehensive assessment of the patient in order to understand their health status before experiencing this health crisis. Therefore the nurse should complete a thorough orientation to the unit, in order to orient the person and their family. This will help with reducing anxiety. Be sure to spend time answering patient and family members questions and concerns. While in the patient room, make sure to identify the various ways to call for help (bedside call bell, washroom call bell, emergency button, calling out for help). The nurse should complete a thorough history and physical assessment in order to elicit information on the patient's medical history, presenting symptoms, functional status, ability to perform ADL's and a thorough baseline head to toe assessment. All of this needs to be documented and shared with the interprofessional team. This information along with other Interprofessional team assessments can serve as a baseline assessment for the patient. This becomes important when trying to prevent and / or address any functional decline or deconditioning experienced due to hospitalization. Hospital Risks Risk Contributing Factors Interventions Delirium is an acute state Medical Factors - multiple Identify and treat the of confusion affecting medications, multiple medical &/or non-medical cognitive function diagnoses, dehydration, cause of delirium pain, infection, hypoxia Encourage family visits & Non-Medical Factors - memory cues unfamiliar environment, Orientation to room, unit & separation for support hospital environment system, stress, Spend time with the patient immobilization or arrange for family to be Impaired vision and hearing present contributes to confusion Ensure vision aids and Nurses inability to reorient hearing aids are used and patient within arms reach "start slow & go slow" with meds © 2022 - Durham College Hospital Risks Risk Contributing Factors Interventions Falls are considered events Presence of equipment or Assistance with ambulation in which the person comes supplies (wires, tubing, Strength & Balance training to rest on the ground, floor monitor leads, urinary Assistance with toileting or lower level (WHO, 2022) catheters, medical devices) Removal of environmental / Getting out of bed tripping hazards independently when Use of bed rails, floor mat assistance is needed sensors and bed alarms Medications (eg: sedatives, Staff, patient & family antihypertensives, education diuretics) Individualized falls Physical restraints - getting reduction assessment and out of bed may cause interventions entanglement * The goal is to minimize Failure to use bed rails risk for falls without Impaired vision compromising mobility & Confusion (delirium or functional independence other forms of cognitive © 2022 - Durham College Hospital Risks Risk Contributing Factors Interventions Dehydration is a Making a patient NPO Mobilize the patient (if reduction in the amount of (nothing by mouth) prior to appropriate) water needed in the body tests, procedures or Orientate to kitchen that results in harm surgeries Provide the patient's Malnutrition is a lack of Medical Factors - nausea, favourite beverages & nutrition vomiting, sedation, altered foods LOC Non-Medical Factors - Inability to access fluids /foods when a patient is unable to reach for fluids/foods, drink or eat independently, or remember to drink & eat; lack of assistance; age related changes in thirst & taste © 2022 - Durham College Hospital Risks Risk Contributing Factors Interventions Urinary incontinence is Delirium - state of acute Interventions should target the involuntary loss of urine confusion the contributing factors in an amount sufficient to A urinary tract infection Urinary log with regular be a problem Excessive urine production voiding opportunities Transient - this may be a result of Environmental incontinence refers to continuous IV fluids modifications to provide incontinence as a result of Medications - such as access to the washroom an acute illness. It is diuretics or sedatives usually temporary Restricted mobility - bed rest, immobility Constipation or impaction © 2022 - Durham College Hospital Risks Risk Contributing Factors Interventions Health Care Associated Age-related reductions in Strict adherence to IPAC Infections are infectious immune system response (infection prevention and diseases acquired within a Most common infections control) practices health care facility are urinary catheter- related Use of appropriate PPE (Personal protective Other health care– equipment) associated infections include surgical site Increase the older person's infection, pneumonia, and resistance to infection blood stream infections. © 2022 - Durham College Hospital Risks Risk Contributing Factors Interventions Skin Breakdown refers to Changes to aging skin (eg: Avoid prolonged pressure to damage to the skin surface thinning) dependent areas Immobility Incontinence Reduce shearing forces and Malnutrition friction Clean skin / perineal area after urine or feces Moisture management Ensure healthy nutrition © 2022 - Durham College Functional Decline & ACE Units Functional decline is described as a decline in physical and / or cognitive function usually as a result of not engaging in activities of daily living while in hospital Significant functional decline can be catastrophic to health of OA Often OA are discharged in worse functional status then when they entered hospital Specialized nursing care with expertise in gerontology is required to minimize functional decline © 2022 - Durham College  Hospitalized older adults can also experience significant functional decline. Evidence shows that when older adults stop performing normal routines or activities, or when they become dependent on others for ADL's they experience this functional decline. In many situations, older adults have been discharged home with a worse functional status then they they entered the hospital with. ACE Units "ACE units are patient-centred care, interprofessional team management, medical review, discharge planning, and assessments and interventions for common geriatric syndromes such as falls, incontinence, confusion, and skin integrity." © 2022 - Durham College Discharge Planning Discharge planning must begin shortly after arrival Goal of discharge must be to prevent the patient from going home sicker and more debilitated then when they arrived ACE strategies assess the following: The patient’s perception of their health status and prognosis The number and complexity of medical conditions Prior history of self-care practices Family or social support Financial resources © 2022 - Durham College All services should be in place prior to discharge. Delirium, Dementia & Depression H&H II – Week 5.5 Cognitive Impairment Older adults may experience a range of cognitive impairment Cognitive Impairment describes a range of disturbances of cognitive functioning, including disturbances in memory, orientation, attention, and concentration. May affect intelligence, judgement, learning ability, perception, problem solving, psychomotor ability, reaction time, and social intactness Common cognitive impairments include: Delirium, Dementia and Depression © 2022 - Durham College delirium, delirium superimposed on dementia, dementia or depression Many characteristics of these diagnoses are similar and so it can be difficult to differentiate and diagnose whether the patient is experiencing delirium, delirium superimposed on dementia, dementia or depression. As a nurse it is important to know the clinical features of each form of cognitive impairment, and to work with the IP team to assess and implement strategies to support the older adult experiencing delirium, dementia &/or depression. © 2022 - Durham College Delirium Delirium is described as a serious acute state of confusion that is prevalent and often preventable in the older adult population. Delirium affects approximately 50% of hospitalized older adults and approx. 6-40% of older adults in LTC Delirium is often mistaken for confusion and / or worsening dementia Delirium is a medical emergency with negative outcomes including compromised overall functioning to mortality. © 2022 - Durham College Delirium Prevention – identify and mitigate risk factors Assessment – baseline mental status Identify – change in mental status Re-Assessment - Confusion Assessment Method or the NEECHAM Confusion Scale or the Delirium Index Identify – root cause of delirium and target © 2022 - Durham College Delirium 6 most common reasons for delirium include: + cognitive impairment, + sleep deprivation, + immobility, + visual impairments, + hearing impairments, + dehydration. © 2022 - Durham College Treating the Root Cause of Delirium Utilize an IP Team approach to initiate specialized Consider environmental factors such as light, services noise Assess and monitor pain & physiological status Maintain normal routines and structure Ensure hydration, nutrition, mobility & sleep Encourage family presence or familiar objects Ensure vision & hearing assistive devices are used Education for all staff working in high incident Avoid restraint use areas Establish consistence in caregivers with a Monitor safety routinely therapeutic relationship Remove tubes and lines is safe (eg: catheter, Orient the patient to the unit monitor or IV) Alter communication to meet the needs of the IP Team to review medications that may contribute patient to delirium Speak clearly and slowly and use gestures if © 2022 - Durham College Dementia Dementia is an irreversible state that progresses over years and causes memory impairment and loss of other intellectual abilities severe enough to interfere with daily life. Approximately 564,000 people in Canada have dementia Estimates 937,000 people in Canada will be dx with dementia by 2031 Alzheimers disease is the most ommon form of dementia (60- 80%) © 2022 - Durham College Key Features of Dementia Aphasia which refers to the loss of ability to express & understand spoken & written language Apraxia refers to the inability to carry out purposeful movements, although motor & sensory abilities are intact Agnosia is the inability to recognize common objects for faces of familiar people despite intact sensory abilities Disturbances in executive functioning which refers to difficulty in planning, organizing, sequencing and abstracting © 2022 - Durham College  There are many forms of dementia including, alzheimers disease, lewy body dementia, vascular dementia, mixed dementia, parkinson's disease dementia, Creutzfeldt-Jakob disease, frontotemportal dementia and normal-pressure hydrocephalus. Because Alzheimers disease is the most common form of dementia, the remainder of this content will focus on the diagnosis, assessment and interventions related to this form Diagnosis of Dementia Diagnosing dementia / Alzheimers disease is very difficult Alzheimers disease is associated with three stages: Pre-clinical Stage - there are changes seen in the brain, CSF and blood, however the person does not demonstrate any symptoms yet. This pre- clinical stage can last up to 20 years before symptoms begin. Mild Cognitive Impairment - signs of mild cognitive impairment begins. The patient or family members will begin to notice memory problems but do not impact the patients overall functioning. Alzheimers Disease - This stage begins prior to diagnosis as symptoms progress to include difficulty with word finding, vision or spatial concerns as well as impaired judgement and reasoning. These symptoms get progressively worse until a diagnosis is made, which can take several years. © 2022 - Durham College  Nursing Implications There is no cure for dementia Functioning can be improved with medication Most important intervention is competent, compassionate and person- cented care Person centred care fosters abilities, supports limitations, ensures safety, enhances quality of life, prevents excess disability and offers hope. © 2022 - Durham College Depression Depression is “a spectrum of mood disorders characterized by a sustained disturbance in emotional, cognitive, behavioural, and/or somatic regulation that is associated with both significant functional impairment in daily living and often loss of one’s capacity for pleasure and enjoyment” (RNAO, 2016, p. 31). Categories of Depression: + chronic, persistent or recurrent or as a response to events + Life transitions (week 2) may precipitate depression © 2022 - Durham College Depression Depression is NOT a normal part of aging When it is assumed as normal this can lead to a lack of diagnosis or treatment Depression can have a significant impact on other co- morbidities Depression can lead to death by suicide in Older Adults © 2022 - Durham College Nursing Implications Recovery is more likely when diagnosis is made and treatments are initiated early Depression is associated with stigma and discrimination Too often depression goes unrecognized and untreated Nurses need the knowledge and skills to assess for depression Treatment will involve an interprofessional approach © 2022 - Durham College Take Home Message Dementia, delirium, and depression are manifestations of serious underlying health challenges. Therefore, any changes in mental status in an older person requires urgent assessment and intervention