Sean Whitfield - NURS 3540 Gerontological Nursing Module 7 PDF

NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide Module 7 Active Learning Guide - Chapters 14,15,16 Purpose/Overview Active learning guides help students focus their study time using knowledge-level information, then concentrate on applying and analyzing knowledge to provide a conte...

NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide Module 7 Active Learning Guide - Chapters 14,15,16 Purpose/Overview Active learning guides help students focus their study time using knowledge-level information, then concentrate on applying and analyzing knowledge to provide a context concerning the course and career skills. Students should review the active learning guide before engaging with the module content, then work to complete the guide both during and after engaging with the content. An active learning guide is not the same as a study guide or a test blueprint. It serves as a guide to help the student navigate the course and content. The active learning guide is not a complete composite of the information needed for the exam but a guide to navigating the content delivery. Instructions Review the active learning guide before you begin reading and engaging with other content in the module. Looking at the questions beforehand will preview the information you will be learning, including the key concepts and takeaways. As you work through the module content, complete the active learning guide. Some questions may be reflective and require that you finish all content before responding. Students will turn in the completed learning guide on Sunday by 1159 pm. Faculty will review, award points, and return them to students to review prior to the exam. There are a possible 5 earned points for this learning guide. Reading Focus Areas In the text, you will see essential boxes, such as Safety Alerts, which discuss issues related to the care of older adults. Research Highlights contain a summary of pertinent current research related to chapter topics. Resources for Best Practice provide suggestions for further information for chapter topics and tools for practice. Healthy People boxes refer to goals cited in Healthy People 2030. Clinical judgment and next generation NCLEX examination style questions are located at the end of every chapter. Please review these questions as they are good practice for the exam. I. Skin 1. Identify age-related changes in the skin. Epidermis Melanocytes decrease Keratinocytes smaller; regeneration slower Noncancerous pigmented spots (freckles, nevi) enlarge Increased lentigine (“age” or “liver” spots) and seborrheic keratosis common Dermatosis papulosa nigra, variant of keratosis in dark skin, increases Dermis 20% loss of thickness Dermal blood vessels decrease Cross-linking increases; collagen synthesis decreases Elastin fibers thicken and fragment Decreased sebum production Hypodermis Shifting of subcutaneous fat; loss of subcutaneous tissue NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide Reduced efficiency of eccrine glands Fewer Meissner’s and Pacinian corpuscles Decreased Langerhans cells 2. What is the most common skin problem experienced by older adults? What is the cause? Xerosis is extremely dry, cracked, and itchy skin. Xerosis is the most common skin problem experienced and may be linked to a dramatic age-associated decrease in the amount of epidermal filaggrin, a protein required for binding keratin filaments into macrofibrils. This leads to separation of dermal and epidermal surfaces, which compromises the nutrient transfer between the two layers of the skin. Xerosis occurs primarily in the extremities, especially the legs, but also can affect the face and the trunk. The thinner epidermis of older skin makes it less efficient, allowing more moisture to escape. Inadequate fluid intake worsens xerosis, as the body will pull moisture from the skin to combat systemic dehydration. Box 14.2 presents Tips for Best Practice in prevention and treatment of xerosis. 3. What is the category used to describe a skin tear without tissue loss? Type 1. What is the nursing management of this type of injury? Skin tear management should preserve any viable skin flap tissue (where possible) and surrounding tissue, approximate (realign) the edges of the wound, reduce the risk of infection (and further injury) and foster healing. Initial management: Control the bleeding and prevent haematoma formation by applying pressure. 4. Why would it be necessary to provide psychological treatment to the patient with herpes zoster? This may have an impact on overall health, feelings of depression, and the immune system. Some researchers think that a weakened immune system can reactivate the varicella-zoster virus. Since stress affects the immune system, many researchers believe that stress could be a trigger for shingles. 5. What condition could be associated with vaginal Candida albicans in an older woman? In the vagina it is also called a “yeast infection.” If this is found in an older woman, it may mean that she has undiagnosed or poorly controlled diabetes. 6. Compare the two most common forms of skin cancer. Compare the risk factors associated with each type. Basal cell carcinoma is the most common malignant skin cancer. It occurs mainly in older age groups but is occurring more and more in younger persons. It is slow growing, and metastasis is rare. A basal cell lesion can be triggered by extensive sun exposure, especially burns, chronic irritation, and chronic ulceration of the skin. It is more prevalent in light-skinned persons. It usually begins as a pearly papule with prominent telangiectasias (blood vessels) or as a scar-like area with no history of trauma (Fig. 14.6). Basal cell carcinoma is also known to ulcerate. It may be indistinguishable from squamous cell carcinoma and is diagnosed by biopsy. Early detection and treatment are necessary to minimize disfigurement. Treatment is usually surgical with either simple excision or Mohs micrographic surgery. NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide Squamous cell carcinoma is the second most common skin cancer. This form of skin cancer is aggressive and has a high incidence of metastasis if not identified and treated promptly. Major risk factors include sun exposure, fair skin, and immunosuppression. Individuals in their mid-60s who have been or are chronically exposed to the sun (e.g., persons who work outdoors, athletes) are prime candidates for this type of cancer. Less common causes include chronic stasis ulcers, scars from injury, and exposure to chemical carcinogens, such as topical hydrocarbons, arsenic, and radiation (especially for individuals who received treatments for acne in the mid-20th century). The lesion begins as a firm, irregular, fleshy, pink-colored nodule that becomes reddened and scaly, much like actinic keratosis, but it may increase rapidly in size. It also may be hard and wart-like with a gray top and horny texture, or it may be ulcerated and indurated with raised, defined borders (Fig. 14.7). Because it can appear so differently, it is often overlooked or thought to be insignificant. All persons, especially those who live in sunny climates, should be screened regularly by a dermatologist. Treatment depends on the size, histologic features, and patient preference and may include electrodesiccation and curettage, Mohs micrographic surgery, aggressive cryotherapy, or topical 5-fluorouracil. Once diagnosed with a squamous cell carcinoma, the person needs to be routinely followed because most recurrences occur within the first few years. Danger Signs for Skin Cancer Danger Signs: Remember ABCDE 7. A Asymmetry of a mole (one that is not regularly round or oval) B Border is irregular C Color variation (areas of black, brown, tan, blue, red, white, or a combination) D Diameter greater than the size of a pencil eraser (although early stages may be smaller) E Elevation and enlargementa What does “never event” mean? Which group introduced the concept? Treatment of PIs is costly in terms of both health care expenditure and patient suffering. In 2008, the Centers for Medicare and Medicaid Services (CMS) included HAPIs as one of the preventable adverse events (health care–acquired conditions [HACs]). The development of a stage/category 3 or 4 PI is considered a “never event” (preventable serious medical error or adverse event that should never happen to a patient). Hospitals no longer receive additional reimbursement to care for a patient who has acquired PIs while in the hospital’s care, and this has the potential to greatly increase the financial strain for facilities that fail to rise to this challenge. In long-term care facilities, when PIs develop after admission and are identified as avoidable, civil monetary penalties can be assessed (Box 14.8). NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide 8. Identify the risk factors for the development of pressure ulcers. 9. What is a “care bundle”? What is the benefit of using a bundle for pressure ulcer prevention? A care bundle is composed of a set of evidence-based practices that, when performedcollectively and reliably, have been shown to improve patient outcomes. Involvement of the patient and family may enhance the effectiveness of care bundles. Core preventive actions include risk evaluation, evaluation of the skin, nutritional evaluation, repositioning, and appropriate support surfaces. Actions that address limited mobility, compromised skin integrity, and nutritional support have been associated with improvements in PI rates. Nurse practitioners assuming a leadership role as wound care consultants in acute care have been found to be instrumental in decreasing HAPI rates (Irvin et al., 2017). II. Nutrition 1. What factors affect the nutrition of the older adult? NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide 2. Define malnutrition. What are the causes of malnutrition? The most common definition of malnutrition is too little or too much energy, protein, and nutrients, which can cause adverse effects on a person’s body and its function and clinical outcomes. 3. What are risk factors for malnutrition? Identify at least three strategies to manage malnutrition. NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide Socialization The fundamentally social aspect of eating has to do with sharing and the feeling of belonging that it provides. All of us use food as a means of giving and receiving love, friendship, or belonging. The presence of others during meals is a significant predictor of caloric intake. Socioeconomic Deprivation There is a strong relationship between poor nutrition and socioeconomic deprivation. Older adults are the fastest-growing food-insecure population in the United States, which means they are not sure where or how they will get their next meal. In 2018, according to the most recent report issued in 2020, 7.3% of all senior households were food insecure (Feeding America, 2020). Older adults are likely to be food insecure if they live in a southern state, have a disability, are younger than 69 years, live with a grandchild, and/or are African American or Hispanic (National Council on Aging, 2018). Transportation Available and easily accessible transportation may be limited for older adults. Many small, longstanding neighborhood food stores have been closed in the wake of the expansion of larger supermarkets, which are located in areas that serve a greater segment of the population. Small convenience stores may not have a selection of healthy foods. It may become difficult to walk to NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide the market, to reach it by public transportation, or to carry a bag of groceries while using a cane or walker. Fear is apparent in older adults’ consideration of transportation. They may fear walking in the street and being mugged, not being able to cross the street in the time it takes the traffic light to change, or being knocked down or falling as they walk in crowded streets. Despite reduced senior citizen bus fares, many older adults remain very fearful of attack when using public transportation. Functional impairments also make the use of public transportation difficult for others. 4. What are the consequences of malnutrition in older adults? Consequences Malnutrition is a precursor to frailty and has serious consequences, including infections, pressure injuries, anemia, hypotension, impaired cognition, sarcopenia (low muscle mass associated with aging) (Chapter 28), hip fractures, prolonged hospital stay, institutionalization, increased dependence, reduced quality of life, and increased morbidity and mortality (Tilly, 2017). Malnourished patients are twice as likely to develop pressure injuries and three times as likely to have infections. Almost half of the patients who fall during hospitalization are reported to be malnourished. There is an increased risk of nosocomial infections as a result of undernutrition, unintentional weight loss, and low serum albumin levels (Bilder, 2016). Finally, older adults who are admitted to the hospital with malnutrition are more likely to have longer hospital stays and die before discharge (Avelino-Silva & Jaluul, 2017). Many factors contribute to the occurrence of malnutrition in older adults (Box 15.5). 5. What is included in the nutritional assessment of an older person? What tools can be used to assess nutritional status or risk for poor nutrition? The Nutrition Screening Initiative Checklist The Mini Nutritional Assessment NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide 6. What is dysphagia? Who is at risk for dysphagia? How is dysphagia assessed, and what interventions may be helpful in preventing aspiration? Dysphagia, or difficulty swallowing, is a prevalent and growing concern in the older adult population. Swallowing is a complex process, with some 50 pairs of muscles and many nerves working together to receive food into the mouth, prepare it, and move it from mouth to stomach. Nurses work closely with speech therapy and the dietitian to implement interventions to prevent aspiration. Compensatory strategies include postural changes, such as chin tucks or head turns while swallowing, and modification of bolus volume, consistency, temperature, and rate of presentation. Diets may be modified in texture from pudding-like to nearly normal– textured solids. Liquids may range from spoon-thick, to honey-like, to nectar-like, to thin. Commercial thickeners and thickened products are also available. The evidence is not strong that texture-modified food and thickened liquids reduce the impact of dysphagia. In addition, patients often do not prefer this kind of food, which may reduce nutritional intake. NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide Screening assessment is important and serves to identify those patients with the greatest risk of dysphagia. It is important to obtain a careful history of the older adult’s response to dysphagia and to observe the person during mealtime. However, screening and swallowing evaluations are not routinely performed. In addition, nurse’s knowledge of dysphagia has been shown to be limited (Artiles et al., 2020; Khalil et al., 2020). Early dysphagia screening and recognition by nurses are considered best practice for acute stroke patients to prevent complications. Symptoms that alert the nurse to possible swallowing problems are presented in Box 15.11. If dysphagia is suspected, a comprehensive clinical assessment of swallowing and referral to a speech-language pathologist (SLP) are essential. A comprehensive exam includes a clinical swallowing evaluation, comprehensive medical history, physical exam of oral and motor function, and assessment of food intake. Instrumental assessment includes videofluoroscopy swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES). Nothing-bymouth (NPO) status should be maintained until the swallowing evaluation is completed. NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide III. Hydration 1. Define dehydration and its development in the older adult. Water-loss dehydration (hypertonic, hyperosmotic, intracellular): Results from insufficient fluid intake, which leads to an elevation of serum osmolarity and a drop in extracellular fluid volume. Volume depletion (hypovolemia) (salt loss, extracellular dehydration): Results from excess fluid loss as occurs in vomiting/diarrhea, excessive bleeding, loss of plasma. Serum is depleted of both fluid and electrolytes. Fluid loss occurs more abruptly than water-loss dehydration. Serum osmolarity may remain stable or decrease slightly. Water-loss dehydration (hypertonic, hyperosmotic, or intracellular dehydration) is common in older adults and results from deficient fluid intake (Hooper et al., 2016). Adults older than 65 years of age have the highest rates of acute care admissions for dehydration as a primary diagnosis. Although the prevalence of dehydration in older adults who are hospitalized has not been adequately studied, rates of 10% to 45% have been reported. 2. What complications are associated with dehydration in the older adult? NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide Thirst sensation diminishes; thirst is not proportional to metabolic needs in response to dehydrating conditions Creatinine clearance declines, kidneys are less able to concentrate urine (particularly in individuals with illnesses affecting kidney function) Total body water decreases Loss of muscle mass and increase in proportion of fat cells; greater in women than men because they have a higher percentage of body fat and less muscle mass; fat cells contain less water than muscle cells 3. Discuss the risk factors for dehydration. 4. Discuss the signs and symptoms of dehydration and the interventions for treatment and prevention. Prevention of dehydration is essential, but assessment is complex in older adults. Cues present differently than in younger individuals, and clinical signs may not appear until dehydration is advanced. Signs and symptoms may be nonspecific, making prevention and early identification of cues important. Skin turgor, assessed at the sternum and commonly included in the assessment of dehydration, is an unreliable marker in older adults because of the loss of NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide subcutaneous tissue with aging. Dry mucous membranes in the mouth and nose, longitudinal furrows on the tongue, orthostasis, speech incoherence, rapid pulse rate, extremity weakness, dry axilla, and sunken eyes may indicate dehydration. Assessment of hydration status must be conducted on admission to the hospital, particularly for those who are frail, and must be monitored regularly throughout the individual’s stay and at discharge (McCrow et al., 2016). In the long-term care setting, the Minimum Data Set (MDS) 3.0 (Chapter 9) assesses for dehydration and fluid maintenance. The diagnosis of dehydration is biochemically proven. Serum osmolarity readings of 300 mOsmol/L or higher are indicative of dehydration in older adults (Hooper et al., 2016). Although most cases of dehydration have an elevated blood urea nitrogen (BUN) measurement, there are many other causes of an elevated BUN-creatinine ratio, so this test cannot be used alone to diagnose dehydration in older adults. Recent research reports that urinary measures reflecting hydration status in older adults (urine color, osmolarity, volume) should not be used because these measures are not sensitive or specific enough. However, urine patterns and color should be observed for changes. 5. How is oral health linked to the general health status of the older adult? Orodental health is integral to general health. Orodental health is a basic need that is increasingly neglected with advanced age, debilitation, and limited mobility. Age-related changes in the oral cavity, medical conditions, poor dental hygiene, and lack of dental care contribute to poor oral health. Older adults who are dependent on caregivers for bodily care assistance exhibit worse oral hygiene than those who are self-sufficient. Poor oral health is recognized as a risk factor for dehydration, malnutrition, and a number of systemic diseases, including pneumonia, joint infections, cardiovascular disease, and poor glycemic control in type 1 and type 2 diabetes. Certain oral and systemic conditions are related to one another (e.g., diabetes and periodontal disease, poor oral hygiene and aspiration pneumonia, dental pain and disruptive behaviors in invididuals with cognitive dysfunction or dementia). A connection between poor oral health and mortality has been identified in a cohort of older adults (Gerontological Society of America, 2021; Kohli et al., 2017). Audio/Video Focus Areas Please watch the following video and answer the questions provided. Staging Pressure Injuries - Wound Care for Nurses (12:01) 1. Define pressure injury: Where we have damage to the skin and or underlying tissue \over a bony prominence or under a medical device due to intense or prolonged pressure. 2. Why do we not use the terminology Pressure Ulcer? Because pressure related wounds do not appear as ulcer’s on the skin. 3. List Bony areas described in video: Elbow, Scapula, Cossiyx, Sacral, heels, hips, ischial tuberosities, 4. Describe each stage of a pressure injury:  Stage I – Skin is intact. Epidermis is damaged NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide Stage II - Damage to epidermis and dermis. Stage III - Damage to epidermis (skin open), dermis and wound extends into subcutaneous  Stage IV – Damage to all layers of skin and wound extends to subcutaneous tissue.  Unstageable – Most of the wound base is covered in eschar or slough and wound base cannot be seen. 5. What does non-blanchable mean? Discoloration of the skin that does not turn white when pressed - is one clinically important skin abnormality (Stage I).   Website Focus Areas Please visit the following websites and answer the questions provided. 1. Skintears.Org Scroll down to the KEY POINTS box. Explain what is involved in a comprehensive risk assessment. A comprehensive risk assessment should include assessment of the individual’s general health(chronic/critical disease, polypharmacy, cognitive, sensory, visual, auditory, and nutritional status), mobility(history of falls, impaired mobility, dependent activities and mechanical trauma), and skin (extremes of age, fragile skin, and previous skin tears). 2. MyPlate What makes the MyPlate for Older Adults different? See p. 175 in the text. Do food groups change? Is it portion size, etc. What supplemental items should be added or taken away to prevent disease? Generally, older adults have lower energy requirements and need fewer calories because they may not be as active and metabolic rates decline. However, they still require the same or higher levels of nutrients for optimal health outcomes. The recommendations may need modification for individuals who have illnesses. The current protein reference nutrient intake (RNI) is 0.8 g protein/kg body weight in healthy adults of all ages. Many older adults fail to consume enough protein. An uneven or skewed protein intake pattern is also common in the United States, with adults typically ingesting the most protein at the evening meal and the least amount at breakfast. Inadequate protein intake along with skewed protein distribution among meals has been associated with reduced muscle protein synthesis, muscle mass, strength, and physical or functional performance. Energy-protein deficiencies can cause a reduction in production of T cells and reduced innate and adaptive immunity, increasing the risk for infection (Bilder, 2016). In a recent study, older adults with higher protein intake had higher bone mineral density at the hip, whole body, and lumbar spine, and a lower risk of vertebral fracture (Weaver et al., 2021). A per-meal high-quality protein intake of 20 to 35 g has been suggested to improve protein syntheses needed for muscle protein repair and maintenance. Search the Healthy People 2030 website and identify the goals that address oral health for older adults. Reduce the proportion of older adults with untreated root surface decay — OH 04 NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide Reduce the proportion of adults aged 45 years and over who have lost all their teeth — OH 05 Reduce the proportion of adults aged 45 years and over with moderate and severe periodontitis — OH 06 Application Questions or Case Studies The following case studies were retrieved from the textbook: Touhy, T.A., & Jett, K.F. (2020). Ebersole & Hess' toward healthy aging: Human needs & nursing response (10th ed.). Elsevier. Case Study #1 An 85-year-old widow lives by herself in the second-floor apartment of a two-family home that she owns. She recently had an aortic valve replacement for severe aortic stenosis. She has a history of atrial fibrillation, hypertension, and osteoporosis. She is s/p resection for colon cancer 5 years ago, for which she received chemotherapy. She has an unsteady gait due to foot deformities. She has three steps to reach her house and 21 steps to reach her apartment. She fatigues easily when climbing the steps. She was driving until her surgery but has not driven since the surgery, waiting for her physician to give her permission. She lives in a high-crime area, but she refuses to move because this has been her home for so long. She has a son and daughter who each live more than an hour away by car. The nearest supermarket is about 20 minutes away. On a recent visit to her primary care provider, she was noted to have lost 13 pounds over the past 2 months. She is 5 feet 4 inches tall and weighs 118 lb, and her BMI is 20.3. She reports eating less, being “too tired to cook and not able to shop.” She states that her son brings her meat from the butcher when he visits, and her sister brings her groceries “but not everything that I ask her for.” She also asks, “Why bother fussing with food? It’s just me.” The wound from her surgery is not yet healed, and she is being treated for a sternal wound infection. She states that she is frequently constipated and takes three prunes and a bowl of bran cereal every morning. She states that she has occasional episodes of incontinence because it takes her a long time to walk to the bathroom, so she is “careful not to drink a lot, especially water.” She states that she drinks “about four cups of good strong coffee a day. That is what I look forward to.” She also reports that she is no longer able to tolerate dairy products, although she used to consume a lot of cheese and yogurt. She states, “The doctor said that I had osteoporosis, so I know dairy products are important, but I can’t digest them any longer.” 1. Is this patient at nutritional risk? If so, identify the specific factors that place her at high risk. Yes. Reports being too tired to cook and not able to shop. Risk for dehydration due to limited water intake, while coffee intake is consistent, due to incontinence ambulating to bathroom. Reports unable to tolerate dairy products. 2. What elements would you incorporate into a diet teaching plan for her? Increase water intake, limit caffeine consumption, add otc lactaid to tolerate dairy and add a protein shake to increase dairy and protein intake. 3. What community referrals would you recommend for her in relation to improving her nutritional status? Why would you recommend these referrals? NURS 3540 – Gerontological Nursing Module 7 Active Learning Guide I would recommend moving to a long term care facility or make arrangements to move her in with one of her children. Either choice will increase social interactions. This increased sociability will increase the patients overall nutritional consumption. Also the patient is a fall risk.