Sean Whitfield - NURS 3540 Module 8 Active Learning Guide Chapter 17 & 18 PDF

NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide Module 8 Active Learning Guide - Chapter 17 & 18 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...

NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide Module 8 Active Learning Guide - Chapter 17 & 18 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 at 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. Urinary Elimination 1. Identify age-related changes that affect bladder elimination and the associated problems experienced by older adults. Kidneys Decreased size and function begins in fourth decade; kidney is 20% to 30% smaller by end of eighth decade Decrease in renal blood flow and glomerular filtration rate (GFR) (less pronounced in healthy individuals) Diverticula of renal tubules in distal portion of nephron Glucose reabsorption decreases (more glucose in the urine) Decline in renal activation of vitamin D decreases intestinal absorption of calcium; more vitamin D is needed to counteract diminishing renal function Ability to concentrate urine decreases; hyperkalemia more common; sudden large changes in pH or fluid load can quickly lead to hypervolemia or hypovolemia. These changes cause a high risk for adverse events if individual is exposed to changes in environment (high temperatures, renal-toxic medications) or to functional restrictions that limit ability to obtain adequate fluids Ureters, Bladder, Urethra Less tone and elasticity Loss of bladder holding capacity NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide Total bladder capacity decreases to 300 mL from 600 mL Urge to void occurs at lower bladder volume (160 to 300 mL) Weakened contractions during emptying, which can lead to postvoid residual and increased risk for bladder infection More urine produced at night; may be due to changes in circadian rhythm, output, or medications, or be indicator of sleep apnea Increased collagen content, changes in gap junctions, increased space between myocytes, and changes in sensitivity of sensory afferents, all of which may contribute to involuntary bladder contractions and overactive bladder symptoms Define urinary incontinence (UI). Define urinary incontinence (UI): UI is the involuntary loss of urine sufficient to be a problem. It is an important yet neglected geriatric syndrome. Discuss the problem of urinary incontinence and how it may affect the quality of life of the older adult. UI affects quality of life and has physical, psychosocial, and economic consequences. UI is identified as a marker of frailty in community-dwelling older adults. UI affects self-esteem and increases the risk for depression, anxiety, loss of dignity and autonomy, social isolation, falls, skin breakdown, and avoidance of sexual activity (Ostaszkiewicz, 2017). Older adults with UI experience a loss of independence and self-confidence and feelings of shame and embarrassment. In a survey of hospitalized older adults, 67% considered bladder and bowel incontinence to be a state the same as or worse than death. “Despite the value individuals place on being continent, many nurses do not consider incontinence to be a clinically important issue” (Ostaszkiewicz, 2017, p. 11). The psychosocial impact of UI affects the individual and family and professional caregivers. The provision of continence care to a dependent individual or an individual with cognitive impairment can be challenging and cause significant distress for both caregivers and care recipients. Continence care is frequently a trigger for agitation or aggression in individuals with cognitive impairment who may perceive intimate personal care interventions as frightening (Chapter 26). Describe the different types of urinary incontinence. Incontinence is classified as either transient (acute) or established (chronic). Transient incontinence has a sudden onset, is present for 6 months or less, and is usually caused by treatable factors such as urinary tract infections (UTIs), delirium, constipation and stool impaction, and increased urine production caused by metabolic conditions such as hyperglycemia and hypercalcemia. Hospitalized older adults are at risk of developing transient UI and also may be at risk of being discharged without resolution of the condition. Use of medications such as diuretics, anticholinergic agents, antidepressants, sedatives, hypnotics, calcium channel blockers, and alpha-adrenergic agonists and blockers also can lead to transient UI. Established UI may have either a sudden or a gradual onset and is categorized into the following types: (1) stress, (2) urge, (3) overflow, (4) functional UI, and (5) mixed UI (Table 17.1). NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide 2. Describe nursing assessment and interventions to promote effective bladder function in older adults. Box 17.6 Tips for Best Practice Teaching About Urinary Incontinence (UI) Interventions Use therapeutic communication skills and a positive and supportive attitude to help individuals overcome any embarrassment about UI. Teach about the range of interventions available for management of UI. Share helpful resources for continence management. Share techniques found useful by others. Collaborate with the individual to help him or her choose the most appropriate and acceptable intervention based on needs. Assist individual to develop a detailed, realistic action plan and set goals. Determine an evaluation plan to assess the effectiveness of interventions. Review progress, identify any barriers to implementation, set alternative goals, or select alternate treatments if indicated. Reinforce effort and persistence. 3. When are antibiotics for treatment of a UTI indicated? The diagnosis of symptomatic UTI is made when the patient has both clinical features (painful urination, lower abdominal pain or tenderness, blood in urine, new or worsening urinary urgency or frequency, incontinence, and fever) and laboratory NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide evidence of a UTI. Treatment is with antibiotics selected by identifying the pathogen, knowing local resistance rates, and considering adverse effects. II. Bowel Elimination 1. Identify age-related changes that affect bowel elimination and describe appropriate nursing interventions to promote elimination. 2. Describe the problem of constipation in the older adult and identify possible causes. Constipation Constipation is defined as a reduction in the frequency of stool or difficulty in formation or passage of stool. The Rome Criteria outline the operational definitions of constipation and should be used as a guide to diagnosis as well as a tool for teaching individuals about constipation (Box 17.12). Constipation is one of the most common gastrointestinal complaints encountered in clinical practice in all settings. Many individuals, both the lay public and health care professionals, may view constipation as a minor problem or nuisance. However, it is associated with impaired quality of life, significant health care costs, and a large economic burden. Constipation also can have very serious consequences, including fecal impaction, bowel obstruction, cognitive dysfunction, delirium, falls, and increased morbidity and mortality. Individuals with chronic constipation are also at greater risk of developing colorectal cancer and benign colorectal neoplasms. Fecal Impaction Fecal impaction is a major complication of constipation. Unrecognized, unattended, or neglected constipation eventually leads to fecal impaction. It is especially common in older adults who are incapacitated and institutionalized and those who require narcotic medications (e.g., end-of-life care). Symptoms and early cues indicating possible fecal impaction include malaise, loss of appetite, abdominal bloating or pain, nausea, vomiting, urinary retention, elevated temperature, incontinence of bladder or bowel, leaking of stool, alterations in cognitive status, fissures, hemorrhoids, and intestinal obstruction. Digital rectal examination for impacted stool and abdominal x-rays will confirm the presence of impacted stool. NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide Continued obstruction by a fecal mass eventually may impair sensation, leading to the need for larger stool volume to stimulate the urge to defecate, which contributes to megacolon. Paradoxical Diarrhea Paradoxical diarrhea, caused by leakage of fecal material around the impacted mass, may occur. Reports of diarrhea in older adults must be thoroughly evaluated before the use of antidiarrheal medications, which further complicate the problem of fecal impaction. Stool analysis for Clostridium difficile toxin should be ordered in patients who develop new-onset diarrhea, especially for those who live in a communal setting or have been recently hospitalized. 3. Describe nursing assessment and interventions to promote effective bowel function in older adults. Solutions, Nursing Actions, and Outcomes NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide Nonpharmacological Treatment The first action in evaluating constipation is to examine the medications the person is taking and to eliminate those that can cause constipation, preferably changing to medications that do not carry that side effect. Medications are the leading cause of constipation, and almost any drug can cause constipation. Nonpharmacological interventions for constipation that have been implemented and evaluated are as follows: (1) fluid and diet related, (2) physical activity, (3) environmental manipulation, (4) toileting regimen, and (5) a combination of these. Fluid intake of at least 1.5 L per day, unless contraindicated, is the cornerstone of constipation therapy, with fluids coming mainly from water. A gradual increase in fiber intake, either as supplements or incorporated into the diet, is generally recommended. Fiber helps stools become bulkier and softer and move through the body more quickly. This will produce easier and more regular bowel movements. High fiber intake is not recommended for individuals who are immobile or do not consume at least 1.5 L of fluid per day. Physical activity Physical activity is important as an intervention to stimulate colon motility and bowel evacuation. Daily walking for 20 to 30 minutes, if tolerated, is helpful, especially after a meal. Pelvic tilt exercises and range-of-motion (passive or active) exercises are beneficial for those who are less mobile or who are bedridden. Exercise and physical activity are discussed in Chapter 19. Positioning The squatting or sitting position, if the individual is able to assume it, facilitates bowel function. A similar position may be obtained by leaning forward and applying firm pressure to the lower abdomen or by placing the feet on a stool. Rocking back and forth while sitting solidly on the toilet may facilitate stool movement. Massaging the abdomen or rectum also may help stimulate the bowel. Toileting regimen Establishing a routine for toileting promotes or normalizes bowel function (bowel retraining). The gastrocolic reflex occurs after breakfast or supper and may be enhanced by a warm drink. Given privacy and ample time (a minimum of 10 minutes), many will have a daily bowel movement. However, any urge to defecate should be followed by a trip to the bathroom. Older adults dependent on others to meet toileting needs should be assisted to maintain normal routines and provided opportunities for routine toilet use. Box 17.14 presents a bowel training program. Pharmacological Treatment When changes in diet and lifestyle are not effective, the use of laxatives is considered. Use of these medications, both prescribed and OTC, is high. The extensive use of laxatives among older adults in the United States can be considered a cultural habit. In the past, weekly doses of rhubarb, cascara, castor oil, and other types of laxatives were consumed and believed by many to promote health. The belief that cleaning out the colon and having a daily bowel movement is paramount to maintaining good health persists in some groups. Providing information about normal bowel function, definition of constipation, and lifestyle modifications can assist in promoting healthy bowel habits without the use of laxatives. Enemas Enemas of any type should be reserved for situations in which other methods produce no response or when it is known that there is an impaction. Enemas should not be used on a regular basis. A normal saline or tap water enema (500 to 1000 mL) at a temperature NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide of 105°F is the best choice. Sodium citrate enemas are another safe choice. Soapsuds and phosphate enemas irritate the rectal mucosa and should not be used. Oil retention enemas are used for refractory constipation and in the treatment of fecal impaction. Alternative Treatments Combinations of natural fiber, fruit juices, and natural laxative mixtures are often recommended in clinical practice, and some studies have found an increase in bowel frequency and a decrease in laxative use when these mixtures are used (Box 17.15). Although research is still limited, many modalities of complementary and alternative medicine, such as probiotic bacteria, traditional herbal medicines, biofeedback, and massage, are also used to treat constipation. III. Sleep 1. Identify age-related changes that affect sleep and describe appropriate nursing interventions to promote sleep. Most of the changes in sleep architecture in healthy adults begin between the ages of 40 and 60 years. The age-related changes include less time spent in N3 sleep (formerly called stages 3 and 4) (slow wave sleep) and more time spent awake or in N1 sleep (formerly called stage 1). The changes contribute to fragmented sleep and early awakening (Suzuki et al., 2017). Declines in N3 sleep begin between 20 and 30 years of age and are nearly complete by the age of 50 to 60 years. In adults older than 90 years of age, N3 sleep may disappear completely (Xiong & Hategan, 2019) (Box 18.1). Time spent in REM sleep also declines with age, and transitions between N1 and N2 (stages 1 and 2) are more common. REM sleep is viewed as important for older adults, since it is a time for the brain to replenish neurotransmitters essential for remembering, learning, and problem solving. Box 18.2 Age-Related Sleep Changes More time spent in bed awake before falling asleep Total sleep time and sleep efficiency are reduced Awakenings are frequent, increasing after age 50 years (>30 minutes of wakefulness after sleep onset in >50% of older subjects) Daytime napping Changes in circadian rhythm (early to bed, early to rise) Sleep is subjectively and objectively lighter (more N1, little N3, more disruptions) Rapid eye movement (REM) sleep is short, less intense, and more evenly distributed Frequency of abnormal breathing events is increased Frequency of leg movements during sleep is increased 2. When do changes begin to occur in healthy adults? Most of the changes in sleep architecture in healthy adults begin between the ages of 40 and 60 years. 3. Describe the stages of sleep. When does most dreaming occur? Box 18.1 The Stages of Sleep Non-Rapid Eye Movement (NREM) 75% of night NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide As we begin to fall asleep, we enter NREM sleep which is composed of N1-N3 (formerly Stages 1-4) N1 Between being awake and falling asleep Light sleep N2 Onset of sleep Becoming disengaged from surroundings Breathing and heart rate are regular Body temperature drops (so sleeping in a cool room is helpful) N3 Deepest and most restorative sleep Blood pressure drops Breathing becomes slower Muscles are relaxed Blood supply to muscles increases Tissue growth and repair occurs Energy is restored Hormones are released, such as growth hormone, essential for growth and development, including muscle development Rapid Eye Movement (REM) 25% of night First occurs about 90 minutes after falling asleep and recurs about every 90 minutes, getting longer later in the night Provides energy to brain and body Supports daytime performance Brain is active and dreams occur Eyes dart back and forth Body becomes immobile and relaxed, as muscles are turned off 4. How is general health affected by sleep? Sleep is a basic need. Sleep occupies one-third of our lives and is a vital function that affects cognition and performance. Sleep is also a barometer of health, and attention to sleep and actions to address sleep concerns should receive as much attention as other vital signs. Research into the physiology of sleep suggests that the restorative function of sleep may be a consequence of the enhanced removal of potentially neurotoxic waste products that accumulate in the awake central nervous system. Short sleep duration (6 hours or less per 24-hour period) and long sleep duration (≥9 to 10 hours per 24-hour period) are both associated with adverse health outcomes. At a population level, the optimal sleep duration in adults for good health is 7 to 9 hours, although individual variability exists. Sleep disturbance and deficiency have been linked with dementia and all-cause mortality. Poor sleep quality, difficulty maintaining alertness, and routine napping also contributed to risk of all-cause mortality. A recent study reported that NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide sleeping fewer than 5 hours a night was associated with a twofold greater risk for incident dementia and that routinely taking 30 minutes or longer to fall asleep was associated with a 45% greater risk for incident dementia (Robbins et al., 2021). 5. Identify the most common sleep disorder. Insomnia Insomnia is the most common sleep disorder worldwide. The American Academy of Sleep Medicine defines insomnia as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that results in some form of daytime impairment (Dopheide, 2020). Diagnostic criteria for insomnia include difficulty getting to sleep resulting in daytime dysfunction in an individual who has an adequate opportunity to sleep. Insomnia is a complex interaction of psychological cognitive arousal and altered circadian and homeostatic mechanisms. Decreased function of the sleep-wake switch with age also may contribute to insomnia. Multiple brain centers work in concert to promote sleep and wakefulness. 6. Why do individuals with dementia experience sleep disruption? Research suggests that the deterioration of a cluster of neurons associated with regulating sleep patterns, the ventrolateral preoptic nucleus, may be responsible for sleep decline in aging. The more neurons that are lost, the more difficult it is for the person to sleep. For individuals with dementia, the link between the loss of neurons is greater and causes more problems with sleep (Petrovsky et al., 2018). The changes that occur in sleep with aging are summarized in Box 18.2. What strategies can be utilized to enhance sleep for the person with Alzheimer’s disease? Allow individual to stay out of bed and out of the room for as long as possible before bed. Provide 30 minutes or more of sunlight exposure in a comfortable outdoor location. Provide low-level physical activity three times a day. Provide meaningful activities (individualized and group) during the daytime. Keep noise level at a minimum, speak in hushed tones, do no use overhead paging, reduce light in hallways and resident rooms. Institute a sleep improvement protocol—“do not disturb” times, soft music, relaxation, massage, aromatherapy, sleep masks, headphones, allowing patients to shut doors. Consider having a kit with music and aromatherapy that can be taken to bedside. Perform necessary care (e.g., turning, changing) when the individual is awake rather than awakening the individual between the hours of 10:00 p.m. and 6:00 a.m. Limit intake of caffeine and other fluids in excess before bedtime. Provide a light snack or warm beverage before bedtime. Discontinue invasive treatments when possible (Foley catheters, percutaneous gastrostomy tubes, intravenous lines). Encourage and assist to the bathroom before bed and as needed. Give pain medication before bedtime for patients with pain. Maintain comfortable temperature in room; provide blankets as needed. 7. What contributing factors to poor sleep need to be considered when performing a nursing assessment for sleep disorders? NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide Box 18.7 Tips for Best PracticeRecognizing and Analyzing Cues: Sleep Disturbances Basic Sleep History Questions Where do you sleep at night (bed, couch, recliner chair)? Do you have any difficulty falling asleep? What do you do at night before you go to bed? Are you having any difficulty sleeping until morning? Are you having difficulty sleeping throughout the night? How often do you awaken and how long are you awake? What prevents you from falling back to sleep? Have you or someone else ever noticed that you snore loudly or stop breathing in your sleep? Do you find yourself falling asleep during the day when you do not want to? Follow-Up Questions What time do you usually go to bed? Fall asleep? What prevents you from falling asleep? Do your legs kick or jump around while you sleep? Are you outside in natural light most days? Do you have any pain, discomfort, or shortness of breath during the night? What type of exercise do you get during the day? Additional Assessment Individual’s bed partner, family member, or caregiver also can be asked to provide information Obtain a medication and substance use history, including prescribed medications, over-the-counter drugs, dietary supplements, caffeine intake Review risk factors (obesity, arthritis, poorly controlled illnesses) Review depressive symptoms: weight loss, sadness, or recent losses Review involvement in social activities Review functional status, activities of daily living (ADL), and instrumental activities of daily living (IADL) performance Objective Measures Sleep diary (keep for 24 hours daily for 2 to 4 weeks) Self-rating of sleep scales—Pittsburgh Sleep Quality Index; Epworth Sleepiness Scale; Insomnia Severity Scale On a scale of 1 to 10 (10 being the highest), how would you rate your sleep? Adapted from Dean GE et al.: Protocol: excessive sleepiness. In Boltz M et al., editors: Evidence-based geriatric nursing protocols for best practice, New York, 2016, Springer, pp 431–441. NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide 8. What is obstructive Sleep Apnea and what are the risk factors for developing sleep apnea? Sleep disordered breathing (SDB) affects approximately 25% of older individuals (more men than women), and the most common form is obstructive sleep apnea (OSA). Untreated OSA is related to heart failure, atrial fibrillation, stroke, type 2 diabetes, cognitive decline, osteoporosis, and even death. OSA is characterized by complete or partial airway closure during sleep. Age-related decline in the activity of the upper airway muscles, resulting in compromised pharyngeal patency, predispose older adults to OSA. A high body mass index (BMI) and large neck circumference have been identified as risk factors for OSA. Losing weight is recommended in obese individuals with OSA, as it improves overall health and reduces the severity of OSA. Weight loss improves OSA by several mechanisms, including reduction in fatty tissue in the throat (i.e., parapharyngeal fat and the tongue). Loss of abdominal fat increases mediastinal traction on the upper airway, making it less likely to collapse during sleep (Wang et al., 2020). Box 18.11 Risk Factors for Obstructive Sleep Apnea Increasing age Increased neck circumference (not as significant in older adults) Male gender Anatomical abnormalities of the upper airway Upper airway resistance and/or obstruction Family history Excess weight Use of alcohol, sedatives, or tranquilizers Smoking Hypertension Activity: Review the risk factors for sleep disturbances. Make a list of the ones you currently encounter in your own life. Discuss how to improve your own sleep quality. Nurses should remember that their own sleep quality is an important part of self-care. Box 18.11 Risk Factors for Obstructive Sleep Apnea Increasing age – Unmodifiable. Male gender – Unmodifiable. Excess weight – Need to restart exercise routine and work less. NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide 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 Ralph Jackson is a 68-year-old African-American male who lives in a low-income housing complex. He has multiple chronic medical conditions including congestive heart failure, diabetes, chronic renal insufficiency, and coagulopathy. He is on multiple medications including diuretics and an anticoagulant. He lives independently but is mostly confined to a wheelchair for mobility. He has frequent appointments related to his various ailments but has a difficult time with compliance, mostly related to the transportation issues. The housing complex he lives in does not provide transportation. Mr. Jackson has one child who is not able to assist him with care needs. The nearest bus stop is approximately 1 mile away and it is very taxing for Mr. Jackson to make his way to the location as frequently as he needs to go. Because of his fixed income, he is unable to afford taxi services. Mr. Jackson tends to have problems with incontinence related to his diuretics. Because of this, he is fearful of taking public transportation to appointments because he is concerned about accidents. 1. What are some of the consequences of urinary incontinence in older adults? Consequences of Urinary Incontinence In most cultures, children are taught early to deal with their own body waste. Deviations from this are socially unacceptable and can lead to chastisement, ostracism, and social withdrawal. UI affects quality of life and has physical, psychosocial, and economic consequences. UI is identified as a marker of frailty in community-dwelling older adults. UI affects self-esteem and increases the risk for depression, anxiety, loss of dignity and autonomy, social isolation, falls, skin breakdown, and avoidance of sexual activity (Ostaszkiewicz, 2017). Older adults with UI experience a loss of independence and self-confidence and feelings of shame and embarrassment. In a survey of hospitalized older adults, 67% considered bladder and bowel incontinence to be a state the same as or worse than death. “Despite the value individuals place on being continent, many nurses do not consider incontinence to be a clinically important issue” (Ostaszkiewicz, 2017, p. 11). The psychosocial impact of UI affects the individual and family and professional caregivers. The provision of continence care to a dependent individual or an individual with cognitive impairment can be challenging and cause significant distress for both caregivers and care recipients. Continence care is frequently a trigger for agitation or aggression in individuals with cognitive impairment who may perceive intimate personal care interventions as frightening (Chapter 26). 2. What type of incontinence does Mr. Jackson have? Functional - Lower urinary tract intact but individual unable to reach toilet due to environmental barriers, physical limitations, cognitive impairment, lack of assistance, difficulty managing belts, zippers, getting a dress up and undergarments down, or sitting on a toilet May occur with other types of UI; more common in individuals who are institutionalized. 3. Discuss some interventions or solutions that may ensure that Mr. Jackson is able to obtain follow-up for his medical conditions. Absorbent Products Some individuals prefer to use absorbent products in addition to toileting interventions to maintain “social continence,” and a wide variety of products are available. Disposable types are available in several sizes, determined by hip and waist measurements, or as one size made to fit all. Many of these undergarments now look like regular underwear, and you even see them in stylish television commercials. Use of Intermittent Catheterization, Indwelling Catheters, and External Catheters NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide Intermittent catheterization is a technique used to manage involuntary loss of urine in individuals with urinary retention related to a weak detrusor muscle (e.g., diabetic neuropathy), those with a blockage of the urethra (e.g., benign prostatic hyperplasia [BPH]), or those with reflux incontinence related to a spinal cord injury. The goal is to maintain 300 mL or less of urine in the bladder. Most of the research on intermittent catheterization has been conducted with children or young adults with spinal cord injuries, but it may be useful for older adults who are able to self-catheterize. It provides an important alternative to indwelling catheterization. Indwelling catheter use is not appropriate in any setting for long-term management of UI (more than 30 days), and there are specific criteria for acceptable reasons for an indwelling catheter (Box 17.9). Hospitalized older adults are more likely to have urinary catheters placed without indication, of which 50% have been shown to have been improperly used. Those with more care needs, cognitive impairment, and pressure injuries are at higher risk of catheter placement (Hu et al., 2017). Reasons for this include (1) convenience to manage UI; (2) lack of knowledge of risks associated with use and alternative treatments; (3) providers not tracking continued use; and (4) lack of valid continence assessment tools for older adults. Misuse of catheterization should be considered a medical error. External catheters (condom catheters) are sometimes used in males who are incontinent and cannot use the toilet. Long-term use of external catheters can lead to fungal skin infections, penile skin maceration, edema, fissures, contact burns from urea, UTIs, and septicemia. The catheter should be removed and replaced daily and the penis cleaned, dried, and aired to prevent irritation, maceration, and the development of skin breakdown. If the catheter is not sized appropriately and not applied and monitored correctly, strangulation of the penile shaft can occur. Pharmacological treatment (anticholinergic, antimuscarinic agents) may be indicated for urge UI and overactive bladder (OAB). Medication includes oxybutynin (Oxytrol, Ditropan, Ditropan XL), tolterodine (Detrol, Detrol LA), trospium chloride (Sanctura), darifenacin (Enablex), fesoterodine (Toviaz), and solifenacin (VESIcare) (National Association for Continence, 2018). All of these medications have similar efficacy in reducing urge UI frequency, and the choice of medication depends on avoidance of adverse drug effects, drug-drug and drug-disease interactions, dosing frequency, titration range, and cost. Beta-3 agonists (mirabegron) are a new class of medications for urge UI and OAB. They should not be used in individuals with severe uncontrolled hypertension, hepatic insufficiency, or bladder obstruction from BPH or in those taking antimuscarinic agents. These medications also can raise digoxin levels (Chapter 11). Move into an assisted living facility, where as a resident can have access to transportation to and from doctor visits. Have a family member attempt to find a ride provider for older adults that is focused on rides to and from doctor appointments. Case Study #2 Charlotte Johnson is an 86-year-old female who has a history of coronary artery disease, asthma, and sleep apnea related to obesity. She was hospitalized in the intensive care unit after having complaints of chest pain. She remained in the ICU for cardiac workup and was later transferred to the cardiac step-down unit, where she could be closely observed. The step-down unit allows nursing staff to access the patients’ bedside more easily and quickly than the regular telemetry unit. The unit contains six beds, each separated by a curtain. After Mrs. Johnson transferred to the specialty unit, she began to exhibit an increase in confusion and patterns of restless sleep. 1. What is a possible cause of Mrs. Johnson’s increase in confusion? Time spent in REM sleep also declines with age, and transitions between N1 and N2 (stages 1 and 2) are more common. REM sleep is viewed as important for older adults, since it is a time for the brain to replenish neurotransmitters essential for remembering, learning, and problem solving. 2. Discuss sleep deprivation in the hospital setting. What are the contributing factors? NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide A multidisciplinary approach to identify sources of noise and light, such as equipment and staff interactions, could result in modification without compromising safety and quality of patient care. Decreasing nighttime noise is important, as sleep deprivation because of noise can potentially exacerbate delirium. Nursing staff should ensure that patients complete a full sleep cycle of 90 minutes before being awakened for nonemergency reasons such as checking for incontinence or doing routine tasks. Other actions are presented in Box 18.9. 3. Identify and discuss nursing interventions to promote sleep in the hospital setting. Box 18.9 Tips for Best PracticeSuggestions to Promote Sleep When Hospitalized or in a Nursing Facility Allow individual to stay out of bed and out of the room for as long as possible before bed. Provide 30 minutes or more of sunlight exposure in a comfortable outdoor location. Provide low-level physical activity three times a day. Provide meaningful activities (individualized and group) during the daytime. Keep noise level at a minimum, speak in hushed tones, do no use overhead paging, reduce light in hallways and resident rooms. Institute a sleep improvement protocol—“do not disturb” times, soft music, relaxation, massage, aromatherapy, sleep masks, headphones, allowing patients to shut doors. Consider having a kit with music and aromatherapy that can be taken to bedside. Perform necessary care (e.g., turning, changing) when the individual is awake rather than awakening the individual between the hours of 10:00 p.m. and 6:00 a.m. Limit intake of caffeine and other fluids in excess before bedtime. Provide a light snack or warm beverage before bedtime. Discontinue invasive treatments when possible (Foley catheters, percutaneous gastrostomy tubes, intravenous lines). Encourage and assist to the bathroom before bed and as needed. Give pain medication before bedtime for patients with pain. Maintain comfortable temperature in room; provide blankets as needed. Pharmacological Treatment National guidelines emphasize that medications for chronic insomnia should be considered only in patients who are unable to participate in CBTI, patients who still have symptoms after this therapy, or those who require a temporary adjunct to CBTI (Edinger et al., 2021). A thorough assessment of sleep concerns is necessary before pharmacological treatment is initiated. The American Geriatrics Society (AGS, 2015) Beers Criteria strongly suggest avoiding any type of benzodiazepine for the treatment of insomnia in older adults because these medications are associated with adverse outcomes, including motor vehicle accidents, impaired cognition, and falls. 4. Discuss the risk factors for obstructive sleep apnea. Box 18.11 Risk Factors for Obstructive Sleep Apnea Increasing age Increased neck circumference (not as significant in older adults) Male gender Anatomical abnormalities of the upper airway Upper airway resistance and/or obstruction Family history NURS 3540 – Gerontological Nursing Module 8 Active Learning Guide Excess weight Use of alcohol, sedatives, or tranquilizers Smoking Hypertension