COA Wellness: Nursing Care of Older Adults PDF

**COA** **COA WELLNESS** **Nursing Care of the Older Adults in Wellness (The Nursing Process)** **Factors that Influence Health Behaviors of Older Adult** - **Cognitive Impairment** - Not understanding the impact of not taking medications or not exercising may lead to a lack of compreh...

**COA** **COA WELLNESS** **Nursing Care of the Older Adults in Wellness (The Nursing Process)** **Factors that Influence Health Behaviors of Older Adult** - **Cognitive Impairment** - Not understanding the impact of not taking medications or not exercising may lead to a lack of comprehension of health behaviors and reasons for engaging in them. As a result, the individual may forget to participate in these activities, or both. - **Function** - Inability to physically engage in health maintenance recommendations such as colonoscopy preparation, completing stool cards, and reading medication directions due to physical limitations. - **Access to Care** - Inability to get grocery stores with appropriate food options. \- Inability to access health care providers because of transportation challenges and insufficient number of providers - **Resources** - Cannot afford health food options and medications. Social Support - May verbally encourage and reinforce healthy behaviors and may help individuals increase access to healthy options - **Sensory Changes** - Inability to see or hear adequately to engage in a behavior (cannot hear or see the directions) - **Environment** - Living space that facilitate physical activity and exercise or does not allow for physical activity - **Unpleasant Sensations** - Pain, fear, boredom and fatigue are common unforgettable sensations that decrease willingness to engage in a behavior such as exercise or getting a screening test done - **Competing Priorities** - Lack of time because of competing responsibilities is frequently used as an excuse for not engaging unhealthy behavior. **Challenges in History Taking in Geriatric Clients** +-----------------------+-----------------------+-----------------------+ | Difficulty | Factors Involved | Interventions | +-----------------------+-----------------------+-----------------------+ | Communication | Diminished Vision | Use a well -- lit | | | | room | | | Diminished Hearing | | | | | Eliminate extraneous | | | Slowed psychomotor | noise | | | performance | | | | | Speak slowly in a | | | | deep tone | | | | | | | | Face patient, | | | | allowing patient to | | | | see your lips | | | | | | | | Use simple | | | | amplification device | | | | for severely hearing | | | | impaired | | | | | | | | Write questions in | | | | large print | | | | | | | | Leave enough time for | | | | the patient t answer | +-----------------------+-----------------------+-----------------------+ | Underreporting of | Health belief | Ask specific | | Symptoms | symptoms | questions about | | | | important symptoms | | | Fear | | | | | Use other sources of | | | Depression | information | | | | (relatives, friends | | | Altered physical and | or caregiver) to | | | physiological | complete the history | | | responses to disease | | | | process | | | | | | | | Cognitive impairment | | +-----------------------+-----------------------+-----------------------+ **Collecting Assessment Data** - Rapport - Never address the patient by the first name unless invited to do so. **Three approaches used for collecting assessment data:** - Self -- report - Report -- by -- proxy - Observation **Self -- report format -** Questions -- asked directly or respond to written questions **Report - by -- Proxy** - Assessment information is obtained indirectly - Used extensively with persons who are cognitively impaired **Observational Approach** - Collects and record the data as they measure or observe using what are believed to be objective parameters **Examples:** - Measurement of BP - Performance -- based functional assessments such as walking. **Health History** - Marks the beginning of the nurse -- client relationship and the assessment process - chief complaint" - Subjective data - **Verbally in a face -- to -- face interview** or using the interview to review a written history completed by the patient or patient's proxy beforehand - **Written format** -- never be used if the person has limited vision, questionable reading level, limited health frequency or written in a language and have inability of reading - **Limited language proficiency** -- a trained medical interpreter is needed - **Limited health frequency** -- special attention will need to be paid to wording of questions and answers to patient's question - **Cognitively impaired** -- additional information should be obtained from the proxy - Patient profile - Past medical history - Review of systems - Medication history - Nutritional history - **Social history** -- current living arrangements, economic resources, family and friend support, community resources **Physical Assessment** - Complete head -- to -- toe (usually done to younger persons) - Assessment is first directed to that which is most likely associated with the presenting problem or major diagnoses - Must be able to quickly prioritize what is the most necessary to know (based on the chief complaint) then proceed to what would be nice to know - CC is not known -- more thorough assessment is always necessary - Well check or health promotion and disease prevention -- emphasis is on the major preventable health problems especially those of cardiovascular and musculoskeletal origin **Comprehensive Physical Assessment of the Frail and Medically Complex Elder** **FANCAPES** - Is a model for comprehensive yet prioritized, primarily physical assessment that is especially useful for the frail elder - Emphasizes determination of very basic needs and the individual's functional ability to meet these needs independently - **Maslow's Hierarchy of Needs** - Fluids, Aeration, Nutrition, Communication, Activity, Pain, Elimination and Socialization **Fluids** - What is the current state of hydration? Does the person have the functional capacity to consume adequate fluids to maintain optimal health? - This includes the abilities to sense thirst, mechanically obtain the needed fluids, swallow them, and excrete them **Aeration** - Is the person's oxygen exchange adequate for full respiratory functioning - Is supplemental oxygen required, and if so, is the person able to obtain it? - What is the RR, depth at rest and during activity, talking, walking, exercising and while performing ADLs? - What sounds are auscultated, palpated, and percussed? - For the older person, it is particularly important to carefully assess lateral and apical lung fields **Nutrition** - What is the mechanical and psychological factors affect the person's ability to obtain and benefit from adequate nutrition? - What is the type and amount of food consumed? - Does the person have the abilities to bite, chew and swallow? - What is the oral health status and what is the impact of periodontal disease if present? - Do their dentures fit properly and are they worn? - Does the person understand the need for special diets? - Has this diet been designed so that it is consistent with the person's eating and cultural patterns? - If the person is at risk for aspiration, have preventive strategies been taught? **Communication** - Is the person able to communicate his or her needs adequately? - Do the persons who provide care understand the patient's form of communication? - What is the person's ability to hear in various environments? - Are there any environmental situations in which understanding of the spoken word is inadequate? - If the person depends on lip- reading, is his or her vision adequate? - Is the person able to clearly articulate words that are understandable to others? - Does the person have either expressive or receptive aphasia and if so has a speech therapist been made available to the person and significant other **Activity** - Is the person able to participate in the activities necessary to meet basic needs such as toileting, grooming, and meal preparation? - How much assistance is needed, if any, and is someone available to provide this if needed? - Is the person able to participate in activities that meet higher levels of needs such as belonging (church attendance) or finding meaning in life? - What are the per- son's abilities to feed, toilet, dress, and groom; to prepare meals; to dial the telephone; and to voluntarily move about with or without assistive devices? - Does the person have coordination, balance, ambulatory skills, finger dexterity, grip strength, and other capacities that are necessary to participate fully in day-to-day life? **Pain** - Is the person experiencing physical, psychological, or spiritual pain? - Is the person able to express pain and the desire for relief? - Are there cultural barriers between the nurse and the patient that make the assessment of or expression of pain difficult? - How does the person customarily attain pain relief **Elimination** - Is the person having difficulty with bladder or bowel elimination? - Is there a lack of control? - Does the environment interfere with elimination and related personal hygiene; for example, are toileting facilities adequate and accessible? - Are any assistive devices used, such as a high rise toilet seat or bedside commode, and if so, are they available and functioning? - If there are problems, how are they affecting the person's social functioning? **Socialization and Social Skills** - Is the person able to negotiate relationships in society, to give and receive love and friendship, and to feel self-worth? **Mental Status Assessment** 1. **Mini -- Mental State Examination (MMSE)** - By Folstein and colleagues - A 30 -- item instrument that has been used to screen for cognitive difficulties - One of he tools often used in the determination of a diagnosis of dementia or delirium - Orientation, short -- term memory, and attention, calculation ability, language and construction - Cannot be given to persons who can't see or write or who are not proficient in English - Score: 30 -- no impairment \< 24 -- potential dementia 2. **Clock Drawing Test** - Used since 1992, a tool to help identify those with cognitive impairment - Used as a measure of severity - Requires manual dexterity to complete - Not appropriate to use with individuals with any limitations in the use of their dominant hand **3. The Mini Cog** - A tool that could establish cognitive status more quickly than MMSE and without the limitations of educational adjustments - Combines one aspect of MMSE with the test of executive function of the Clock Drawing Test - Highly sensitive to diagnosing dementia **4. The Global Deterioration Scale** - A classic measure of the levels of cognitive changes as one passes through the process of dementia - Useful to both the nurse and the family to develop appropriate interventions to help the person optimize his or her health and anticipate future needs and changes **Mood Measures** **Geriatric Depression Scale** - To determine the presence or absence of depression, a common and too often unrecognized problem in older adults. **Geriatric Depression Scale** - Successful in determining depression - It deemphasizes physical complaints, sex drive and appetite -- those things affected by medications - Cannot be used in persons with dementia or cognitive impairment **Functional Assessment** - Identifying the specific areas in which help is needed or not needed - Identifying changes in abilities from one period to another - Assisting in the determination of the need for specific service(s) - Providing information that may be useful in determining the safety of a particular living situation **Activities of Daily Living (ADLs)** - Katz Index - Barthel Index - Functional Independence Measure (FIM) Activities: Eating Toileting Ambulation Bathing Dressing Grooming **Katz Index -** Developed in 1963 - Served as basic framework for most of the measures of ADLs Versions: - 4 -- point scale: allows one to score performance abilities as independent, assistive, dependent, or unable to perform - 1 point to each ADL that can be completed independently - Zero (0) if unable to perform these activities Scores: 6: totally independent; 0:totally dependent 4: moderate impairment; \