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Senior Health Dr. Meryem ERCEYLAN Contents Global Elderly Population Elderly Population in TURKIYE Culture and Elder Health Health Assessment of Older Adults Environmental Conditions Social Conditions Psychological Conditions Normal Aging Changes to Body Systems Health Promotion for Older Adults Glo...

Senior Health Dr. Meryem ERCEYLAN Contents Global Elderly Population Elderly Population in TURKIYE Culture and Elder Health Health Assessment of Older Adults Environmental Conditions Social Conditions Psychological Conditions Normal Aging Changes to Body Systems Health Promotion for Older Adults Global Elderly Population In worldwide, individuals aged 65 years or older are an important and growing segment of the population. Life expectancy is increasing; thus, larger numbers of people are reaching 65 years of age and older. Global Elderly Population According to the United Nations population estimates, the world population was 7 billion 975 million 105 thousand 156 people, and the elderly population was 782 million 998 thousand 642 people in 2022. According to these estimates, 9.8% of the world population was elderly population. Global Elderly Population Elderly Population in TURKIYE Elderly population became nearly 8 million persons While the proportion of the elderly population in the total population was 8.5% in 2017, it increased to 9.9% in 2022. According to the population projections, the proportion of elderly population was expected to be 12.9% in 2030, 16.3% in 2040 and 22.6% in 2060 Concept of Aging Aging is a natural process that affects all living organisms. The concept of aging is most often defined chronologically. Chronological age refers to the number of years a person has lived The young-old (aged 65 to 74 years), the middle-old (aged 75 to 84 years), the old-old (aged 85 to 99 years), and the elite-old (more than 100 years old) are four distinct cohort groups. Concept of Aging Functional age, on the other hand, refers to functioning and the ability to perform activities of Daily living (ADLs), such as bathing and grooming, and instrumental activities of Daily living (IADLs), such as cooking and shopping. After all, most older adults are more concerned with their functional ability than their chronological age. Assisting older adults to remain independent and functional is a major focus of nursing care. Culture and Elder Health As the older adult population is dramatically increasing in size, so too is it more diverse. Geographic origin, historical events, cohort position, and gender contribute to these cultural differences. Culture and Elder Health Culture refers to shared values, beliefs, and behavior by members of a society that serve as guides for interacting within the family, community, and country. Adherence to cultural values, beliefs, and behaviors is variable based on factors such as age, education, social and educational status, language use of the dominant culture, and setting such as urban or rural. Culture and Elder Health The meanings of health, illness, and health care practices as well as end-of-life issues are imbedded in values, beliefs, and practices of the culture of the older adult. Cultural competence and sensitivity indicate an understanding of the issues related to culture, race, gender, social class, and other factors and encompass knowledge, attitudes, and mutual respect. Health Assessment of Older Adults Many misconceptions surround older adults, especially concerning health and wellness. The truth is that the overwhelming majority of older adults lead independent lives even though they have chronic illnesses and some level of disability. Negative stereotypes of older adults are termed ageism and public health nurses should dispel misconceptions and ageism in their practice. Health Assessment of Older Adults Myths of Aging Older adults cannot live independently. Older adults are not happy. Older adults will have dementia or Alzheimer’s. Older adults are not productive. Older adults cannot enjoy physical activity. Older adults are not sexually active. Older adults refuse change. Health Assessment of Older Adults Overall, health and wellness of older adults are influenced by the individual degree of disability and physical illness, the ability to cope with difficulties, individual resilience and adaptability, and the level of familial and societal support for individual difficulties. Health Assessment of Older Adults It is the responsibility of the public health nurse to be able to assess the health status of older adults and to recommend support services where needed such that the older adults capitalize on their own abilities and minimize their difficulties. Health Assessment of Older Adults Public health nurses must be able to recognize social, psychological, and environmental issues that are more prevalent among older adults. Likewise, public health nurses need to recognize the physical signs and symptoms of normal aging with signs and symptoms that represent disease and injury. Health Assessment of Older Adults When assessing the older adult, public health nurses need to know the various effects environmental, social, psychological, and physical conditions have on the health of older adult populations. Environmental Conditions There are many environmental concerns for the older adult; but the most important are adequate food and housing. First, the public health nurse must assess the ability of the older adult to pay for municipal services that include power, temperature control in the home, running water, food, medicines, and medical supplies. The public health nurse must recognize home safety hazards in the home that would make it easy for an older person to fall such as poor lighting, area rugs, and stairs. Safety concerns including fire hazards and lack of smoke detectors should be noted. The kitchen should be assessed for both safety and function. The public health nurse should note any small appliance in the home that is a potential risk for electrocution or fire. Environmental Conditions Within the living environment, the public health nurse should assess if there is food available and if food can be easily obtained from a local market or delivery service. The overall neighborhood of the older adult should be assessed for safety including the availability of transportation, access to needed services, and nearby neighbors, as well as reported crime and violence rates. Social Conditions Social support systems are vital to the health and wellness of older adults. Social support has been found to be extremely important in aging successfully and in promoting and maintaining overall long-term health by supporting engagement in life and by contributing to physical and cognitive functioning. Conversely, social isolation or disengagement is a risk factor of cognitive decline in cognitively intact elders. Social Conditions The public health nurse must ask about and identify those persons who are available to assist the client and provide social support. The public health nurse must also assess other resources of elders such as financial status. It is necessary then for the public health nurse to ask about and identify the economic status of the older adult and their ability to purchase food, housing, and medical services. Psychological Conditions Older adults who have the opportunity to participate in routine activities, stay involved in meaningful activities, and feel productive in life age successfully and have brighter healthier psychological outlooks than older adults who are limited by multiple debilitating illnesses and physical disabilities that prevent them from remaining active and at home. Psychological Conditions Short-term memory loss is common in older adults, which may affect their psychological health. It is the responsibility of the public health nurse to distinguish normal memory loss from more severe dementia or Alzheimer’s disease. Personal losses of family members and friends can lead older adults to have feelings of despair and depression Sleep disturbances can also contribute to depression. Severe depression is not a result of normal aging. Psychological Conditions Public health nurses should promote successful aging and overall happiness for the older adult client by encouraging older adults to continue physical activities and social engagements with friends and families. Public health nurses need to emphasize to older adults the necessity to maintain adequate nutrition, exercise, and rest along with health care prevention and maintenance Normal Aging Changes to Body Systems Physiologic changes are a normal part of aging. The degree to how quickly these changes occur varies among individuals. All of the vital systems are affected with age including cardiovascular, pulmonary, gastrointestinal, urinary, musculoskeletal, neurological integumentary, reproductive, and special senses Normal Aging Changes to Body Systems Cardiovascular System Coronary artery disease is the most common cause of death in older adults. Blood pressure rises with age, and the overall cardiac reserve diminishes. Arrhythmias, murmurs, and dilation of the abdominal aorta are also more common in older adults, which may lead to chronic cardiovascular disease. Stroke is the third leading cause of death and the number one cause of disability in older adults. Elevated blood pressure is the number one cause of stroke in older adults. Normal Aging Changes to Body Systems Pulmonary System There is a mild decline in pulmonary function including decreased elasticity of alveolar sacs and mucous transport resulting in shortness of breath. However, the majority of pulmonary dysfunction is caused by disease, primarily due to tobacco use, and is not associated with normal agerelated changes to the pulmonary system. Normal Aging Changes to Body Systems Gastrointestinal System Dental changes are the most universal, especially gum disease and tooth loss. Peristalsis slows through the gastrointestinal system, causing constipation, malabsorption, and esophageal reflux. Often, these conditions are caused by poor diets, drug effects, or underlying disease. The liver and pancreas reduce in size, but without disease their function remains adequate. Normal Aging Changes to Body Systems Urinary System Age reduces the peak bladder capacity, and the amount of residual urine increases. The amount of renal blood flow is halved, and the renal tubules are less able to concentrate urine, requiring the kidneys to work through the night when blood flow is increased. Symptoms among women resulting from these changes include nocturia, urgency, and incontinence. Prostatic hypertrophy is common among males resulting in nocturia, decreased urinary stream, and urinary hesitancy. Normal Aging Changes to Body Systems Musculoskeletal System There are many significant musculoskeletal changes that occur with aging. Muscle mass decreases by 30 percent leading to decreased strength and endurance. Normal aging also can result in slow foot reaction time The hands may be affected with the fingers loosing strength and the ability to grasp objects. Osteoporosis is the leading cause of musculoskeletal disability in women. Women older than age 60 should be screened regularly for bone density loss Sarcopenia is the normal loss of muscle mass and affects both men and women. Normal Aging Changes to Body Systems Neurological System Neurological changes can be profound causing numerous changes in function. The most important functional changes cause swaying when going from a sitting to standing position and the inability to stand without swaying with eyes closed. Some medications for cardiovascular disease and elevated blood pressure may enhance these types of side effects. Dehydration may also cause dizziness. Neurological symptoms should be assessed carefully examining medications and nutritional status. Normal Aging Changes to Body Systems Integumentary System Perspiration decreases, and then the skin becomes cool and dry. The skin has increased pigmentation, increased cherry angiomas, and wrinkling. Older adults become more susceptible to skin cancers. The hair becomes thinner and gray. Nails thicken and develop ridges. Normal Aging Changes to Body Systems Reproductive System: For post menopausal women, the ovaries and uterus atrophy. Vaginal secretions become scant, the vaginal mucosa becomes thin and friable resulting in painful intercourse and the need for lubrication, pubic hair decreases, and the breasts become more pendulous. Women may experience complaints with menopausal symptoms such as hot flashes, night sweats, and mood fluctuations. For older men, the prostate enlarges, while the size of testes decreases, and pubic hair thins. Sexual activity does put older adults at risk for developing sexually transmitted diseases and HIV infections, and older adults should be counseled in prevention Normal Aging Changes to Body Systems Special Senses: Beginning around 40 years of age, near vision changes, making it difficult to see objects at close distances. The most common complaint is the need for reading glasses. Light that is able to enter the eye decreases due to reduced pupil size, yellowing to the lens, and opacification of the lens. These changes result in the inability to discriminate blue from green, inability for the eye to adjust from a lighted room to a dark room, and sensitivity to glare. The most common complaint is difficulty in driving at night due to “night blindness.” Excessive opacification to the lens is considered a cataract, which may require surgical removal. Normal Aging Changes to Body Systems Special Senses: High-frequency hearing loss, called presbycusis, is common among older adults. Difficulty hearing sounds of words makes it difficult to interpret speech or to interpret what is being heard in noisy surroundings. Diminished sense of taste and smell may lead to overseasoning foods with salt or sugar. Diminished sensitivity to temperature may lead to overheating food and water temperatures, which increases the risk of burns either when showering or eating. Older adults should be cautioned to test water and food temperature with the wrist or arm and not the fingers and toes to avoid burns. Health Promotion for Older Adults Older adults should be encouraged to participate in illness prevention to improve quality of life throughout the latter years. Illness prevention recommendations for older adults include health screenings and immunizations, education regarding substance abuse, diet and exercise, sexuality, and preventing injuries. Health Promotion for Older Adults Health promotion is the process of enabling people to increase control over & improve their health by developing their resources to maintain or enhance well being. Health promoting is an action for health using knowledge, communication & understanding Health Promotion for Older Adults Health promotion involves making lifestyle and behavior changes in order to move toward optimal health. Health promotion efforts include: Increasing awareness of health issues Promoting healthier behaviors Creating supportive environments Developing preventive strategies Encouraging early detection and treatment Health Promotion for Older Adults Objectives of health promotion Increase quality and years of healthy life Maintain function Eliminate health disparities and promote independency Improve (enhance) quality of life Extend life expectancy → ↓ premature mortality caused by chronic& acute diseases Health Promotion for Older Adults Component of health promotion 1. 2. 3. 4. 5. 6. 7. 8. 9. Exercise Nutrition Rest & sleep Periodic medical check up High risk behavior Spiritual well-being Psychosocial well-being Safety measures Stress management Component of health promotion 1. Exercise Physical Benefits of exercise Psychological Social Component of health promotion 1. Exercise Physical benefits of exercise 1) Consumption of body fat 2) Improve cardio-vascular capacity( by↑ blood flow---- - keep tissue healthy 3) Control hypertension& blood sugar 4) Improve respiratory function 5) Improve joint flexibility 6) Improve pattern of sleep & rest 7) ↑ independency 8) Improve sense of well –being & relaxation 9) Maintain mind’s function 10) Promote sense of normality 11) Peristaltic movement Component of health promotion 1. Exercise Psychological benefits of exercise 1. Improve mood state 2. Improve self-image 3. Reduce stress & anxiety 4. Enhance sleep 5. Improve depressive state of elderly 6. Improves Cognitive Function 7. Helps with memory and concentration 8. Improves mood Component of health promotion 1. Exercise Social benefits of exercise 1. Improve social interaction & relation with other 2. Improves Social Function 3. Increases independence 4. Increases social networks and involvement 5. Enables person to participate in and enjoy social activities more Component of health promotion 1. Exercise Role of the nurse during exercise I- Assessment done at the beginning of exercise program include: 1. History & physical examination (CVS, resp, musculoskeletal & neurological system) 2. Renal & liver function tests 3. ECG,& exercise stress test 4. Assess range of motion & use of assistive devices. 5. Assess environmental hazards II-Set a regular time to exercise each day Component of health promotion 2. Nutrition It is neglected especially those living alone or with low income. Factors affecting nutritional status: 1. 2. 3. 4. Age related changes Psychosocial factors Economic factors Cultural factors Component of health promotion 2. Nutrition Factors affecting nutritional status: Age related changes ↓ Taste & smell ↓ Visual acuity Loss of teeth & poor fitting denture ↓ Gastric secretion→ influence in absorption of B12, folic acid& iron. Food remain longer time in stomach + ↓ gastric secretion will lead to indigestion &feeling of fullness. Component of health promotion 2. Nutrition Factors affecting nutritional status: Psychosocial factors Depression is common ( losses, death, retirement, change of body appearance, impaired vision &poor physical fitness) this will lead to lack of interest in eating& anorexia and ↓ food intake. Living alone also will lead to lack of incentive to cook &eat. Component of health promotion 2. Nutrition Factors affecting nutritional status: Economic Factors Low income Limited access to food and food choices Inadequate facilities to food storage and preparation Component of health promotion 2. Nutrition Factors affecting nutritional status: Cultural factors Eating habits may miss certain food group as vegetarians. Component of health promotion 2. Nutrition Important of nutrition It has been estimated that 10 to 25 percent of elderly people suffer from poor nutrition Poor nutrition can contribute to: – Heart disease – Cancer – Diabetes – Depression – Anemia – Frailty – Obesity – Osteoporosis – Isolation Component of health promotion 2. Nutrition Barriers to Good Nutrition Disability Changes in appetite Difficulty shopping Difficulty cooking Depression or anxiety Nausea Medication side effects Dental problems Swallowing problems Poor vision Financial problems Social isolation Transportation problems Other medical conditions Component of health promotion 2. Nutrition Overcoming Barriers to Good Nutrition Chewing problems – juices, canned fruits, creamed or mashed vegetables, eggs, cooked cereals Difficulty shopping – Look into grocery delivery or shopping services, ask friends, family, church members for help Difficulty cooking – Try microwaveable meals, group dining programs Poor appetite – Eat with others, ask doctor if medicine side effects could be causing problems, try different spices Financial concerns – Use coupons, share with someone, try low-cost options such as beans, bean soups, whole grain cereals, look into food bank programs or other community assistance For expert help – Talk to doctor about a referral to a registered dietician Component of health promotion 2. Nutrition Nurse Role Assessment involves: nutritional history, physical examination, anthropometric measurements, biochemical evaluation, cognitive & mood evaluation Health history related to nutrition Anthropometric measurement Client and family education Component of health promotion 3. Rest& sleep Person spend 1/3 of his life in sleep Sleep is time for cell growth& repair Elderly need 5-7 hrs at night Importance of Rest& sleep: 1. Conserve energy 2. Provide organ respite (rest) 3. Restore the mental alertness& neurological efficiency 4. Relieve tension 5. Emerge feeling of well being Component of health promotion 3. Rest& sleep Important Things to Know About Ageing and Sleep Older people usually sleep as much each day as younger adults. Older people often take daytime naps as well as sleeping at night. Age increases the risk of some sleep disorders. Medical conditions that arise with ageing can disrupt sleep. Sleeping pills are best used only for short periods of time. Try to go to bed and get up at the same time each day Component of health promotion 3. Rest& sleep Self-Care at Home cont……. Maintain a regular wake-up time. Maintain a regular time to go to sleep. Avoid or decrease daytime naps. Exercise daily but not immediately before bedtime. Use the bed only for sleeping or sex. Do not read or watch television in bed. Do not use bedtime as worry time. Avoid heavy meals at bedtime. Component of health promotion 3. Rest& sleep Self-Care at Home cont……. Avoid or limit alcohol, caffeine, and nicotine before bedtime. Maintain a routine period of preparation for bed, (for example, washing up and brushing teeth). Control the nighttime environment with comfortable temperature, quietness, and darkness. Wear comfortable, loose-fitting clothes to bed. If unable to sleep within 30 minutes, get out of bed and perform a soothing activity, such as listening to soft music or reading, but avoid exposure to bright light during these times. Get adequate exposure to bright light during the day. Component of health promotion 3. Rest& sleep Nursing measures adopted to promote sleep 1. Engage in exercise program 2. Avoid exercise within 3-4 hr. of bedtime. 3. Spend time out door in the sunlight each day but avoid period between 12 Md to 3 PM sunshine exposure. 4. Engage in relaxing activities near bedtime. 5. Avoid tobacco at bedtime 6. Avoid drink any caffeinated beverages before mid afternoon. 7. Limit fluid intake after the dinner hour if nocturia is a problem. 8. Limit daytime naps to 30 minutes or less. 9. Avoid using the bed for watching TV, writing bills, and reading Component of health promotion 4. Periodic medical examination Importance of Periodic medical examination: 1. 2. 3. 4. 5. Assess elderly level of well-being Detect early signs of disease Educate client how to promote his health Reinforce + ve promoting & protecting behaviors If examination done at home, it permit evaluation of environment ( hazards care giver…) Component of health promotion 4. Periodic medical examination Types of health screening Dental check up Once / year( annually) Fecal occult blood& sigmoidoscopy Annually Vision including glaucoma test Every 2 years Hearing Evaluate periodically Cholesterol level Every 5 years Cancer screening Annually Mammography for women nunder 70 y Digital rectal examination 1-2 years Annually Component of health promotion 5. High Risk Behavior It is behavior that damage physical health. It includes: 1. Over the counter medication (multiple medications ) 2. Smoking 3. Caffeine Component of health promotion 5. High Risk Behavior Multiple medication Older people consume many medication-------- ↑adverse drug reaction The most common over the counter medication: Analgesics, laxatives& antacids followed by cough products, eye wash& vitamins. Component of health promotion 5. High Risk Behavior It is behavior that damage physical health: Smoking Nicotine & toxic substances in cigarette has impact on detoxication process in the body------- cell damage& variety of diseases as cancer, respiratory, CVD, ↑ risk of osteoporosis Cessation of smoking improves cerebral blood flow& ↑ pulmonary function Component of health promotion 5. High Risk Behavior Caffeine Found in coffee, tea, soft drinks, chocolate It is mood elevator It stimulates sympathetic nervous system ↑motor activity ↑ muscle capacity & alertness ↑ Rapid pulse ↑ calcium excretion Component of health promotion 6. Spiritual Well- being Spiritual well-being is the practice and philosophy of the integral aspects of mental, emotional and overall wellbeing. Spiritual well-being is a state in which the positive aspects of spirituality are experienced, incorporated and lived by the individual and reflected into ones environment. Component of health promotion 6. Spiritual Well- being Signs of spiritual distress: Doubt Despair Guilt Boredom Expression of anger toward god Component of health promotion 6. Spiritual Well- being Benefits: The practice and incorporation of Spiritual Wellbeing into one’s life influences and includes benefits for ones; Emotional Wellbeing, Physical Wellbeing, and Mental Wellbeing. Component of health promotion 6. Spiritual Well- being Some of the measurable benefits that people experience from spiritual wellbeing counseling and groups include: A feeling of being more contented with their life’s situation Greater enjoyment of self time, finding an inner peace Greater ability to take control of and resolve their life’s issues A greater sense of satisfaction in their activities and life situations Ability to take a more active part in life rather than standing still and watching it pass by Ability to build more intimate, loving and lasting relationships A greater feeling of purpose and meaning in their life Component of health promotion 7. Psychosocial Well- being Psychosocial changes may alter an individual relationship with others. Physical wellbeing depend on: Psychosocial wellbeing Social structure Personal relationships In Later years many adjustment are necessary Role of the nurse in health promotion Assessment to his physical health, Psychosocial Well- being, lifestyle pattern, hobbies, high risk behaviors, knowledge, believes& attitudes that affect health & wellbeing. Assess health needs Assess social , environmental & cultural influences on health behaviors Lifestyle modifications is a comprehensive approach for effective change in heath promotion behaviors Nurse role should directed toward helping elderly to cope with his function level ------delay disabilities & impairments. Role of the nurse in health promotion Nurse identify environmental hazards & make necessary modifications Identify social needs & encourage participation & social support groups. Nurse should inform elderly & caregivers about aging process, common disorders & disabilities , different services available Encourage elderly to take better care to them, avoid high risk behaviors,& hazards affecting their health. Regular and continuous evaluation is important aspect of nurse’s role. Homecare Nursing Dr. Meryem ERCEYLAN Elderly population, Total, % of population, 2022 (OECD, 2024) Elderly population, Total, % of population, 2012 – 2022 (OECD, 2024) Elderly population, Total, % of population, 2012 – 2022 (OECD, 2024) Old-age dependency ratio (OECD, 2024) Old-age dependency ratio (OECD, 2024) Cost effectiveness of home care versus hospital care: a retrospective analysis (Megido et al., 2023) Life expectancy at birth (years) (WHO, 2024) Social changes… Industrialization and urbanization, Change of family structures, transformation from extended family to nuclear family Increase in the number of women taking part in working life Decrease in caregiver roles in the family Historical Perspective William Rathbone (1819-1902), the Liverpool merchant and philanthropist, employed Mary Robinson to nurse his wife at home during her final illness. William Rathbone decided to try to extend the service started with Mary Robinson There was a lack of trained nurses. In 1860 he wrote to Florence Nightingale, who advised him to start a nurse training school and home for nurses The city was divided into 18 ‘districts’, Each district was under the charge of a Lady Superintendent drawn from wealthy families who were expected to underwrite the costs of the scheme and provide accommodation for nurses. Historical Perspective In 1893, Lillian Wald began home visiting in New York City and is famed for professionalizing visiting nursing. One of her most famous collaborations was with insurance companies for payment of home care services. Between 1909 and 1952, 100 million home visits were made to the policyholders of Metropolitan Life Insurance Company. By the end of the 19th century, urbanization, industrialization, immigration, and the constant danger of infectious diseases were transforming most large cities into increasingly unhealthy places to live. Historical Perspective After 1940, due to the great decrease in the number of nurse-health personnel in hospitals during World War II, home nursing increased qualitatively and quantitatively as those who needed hospital treatment were treated at home. Less expensive alternatives to hospital care were sought in the 20th century. Private home health agencies evolved from the demand to provide care for the chronically ill client in their home. Payment for home health care visits via Medicare and health insurances has allowed the individuals to rehabilitate at home, and that has proven to increase patient satisfaction and therefore promote positive outcomes while being cost-effective Historical Perspective Türkiye: 10.03.2005- Regulation on the Provision of Home Care Services 01.02.2010- Directive on the Implementation Procedures and Principles of Home Health Services Provided by the Ministry of Health 27.2.2015- Regulation on the Provision of Home Health Services by the Ministry of Health and Affiliated Institutions Home care services have been provided in the private sector since 2005 and in the public sector since 2010. Historical Perspective Türkiye: In 2017, the law on health organization was amended by the Decree Law. -With the amendments, the primary care pillar of home health services has been abolished. -It continues to be carried out by public hospitals. -Palliative care centers continue to serve in secondary and tertiary care hospitals. Ministry of Health, General Directorate of Public Hospitals, Department of Health Services - Ministry of Health Home Health Services Coordination Center: 444 38 33 - Applications received by the National Call Center reach the coordination center Istanbul Metropolitan Municipality- home health Application: Alo 153 http://www.ibb.gov.tr address Social pre-assessment teams visit their homes as soon as possible and determine the social status of the patient. As a result of the preliminary evaluation, the files of the individuals who are eligible for service are directed to the evaluation doctor and they are provided with Home Health Services. Home Health Care Users Orthopedics, traumatology patients, Diabetic patients, neurology patients Cardiovascular and hypertension patients New mothers and their babies Those who need laboratory examination and testing services Those who need all kinds of medical equipment at home Home Health Care Users Prematurely born infants on ventilators, Children with diabetes requiring insulin injections, Young adults with AIDS who must adhere to complicated medication regimens, Middle-aged adults with “silent” hypertension that requires medication with unpleasant side effects, Older adults with sleep apnea who must use uncomfortable equipment to maintain continuous positive airway pressure, People with renal failure who use home dialysis to avoid costly kidney transplants Children and adults also experience acute conditions such as infections (influenza) and injuries (broken bones) Characteristics of Caregivers Formal caregivers: professionals include nurses, physicians, therapists (including physical therapists, speech and language therapists, and occupational therapists), dieticians, and social workers Direct-care workers: home health aides, companions Informal caregivers: family members ❖While physicians generally have the formal responsibility for ordering home care services, home care nurses or physical therapists often develop the plan of care, based on their knowledge and expertise, and send it to the physician for approval. ❖Direct-care workers’ responsibilities include personal care, housekeeping, companionship, and assistance with activities of daily living Homecare Providers American Nurses Association (ANA) Scope and Standards of Practice for Home Health Nursing 1-Assessment: family dynamics, knowledge of caregivers, patient values/goals/health beliefs 2-Diagnosis: validation of diagnosis with patient/family, actual and potential risks, health barriers 3- Outcomes identification: Collaboration with patient/family to identify goals, consideration of cultural, ethical, and personal beliefs and values American Nurses Association (ANA) Scope and Standards of Practice for Home Health Nursing 4- Planning: collaborating with patient/family on an individualized plan of care, strategies to address health promotion and restoration, prevention of injury/illness, pain relief/palliative care, interprofessional collaboration regarding care, planning for transitions to and from home health care. 5-Implementation collaboration on implementing plan of care, engaging patients in disease management, use of evidence-based practice interventions, providing holistic care, utilizing health care technologies and community resources, integrating complementary practices with traditional approaches, promoting problem solving behaviors in patients/families American Nurses Association (ANA) Scope and Standards of Practice for Home Health Nursing 6- Coordination of care: collaborating with team members, helping patients/families recognize alternative care options when plan of care no longer meets patient needs, works closely with patients/families during care transitions) 7- Health Teaching & Health Promotion: developmentally and culturally sensitive health promotion/teaching that promotes patient engagement with self-care, utilizes information and health care technologies as appropriate 8- Consultation: synthesizing evidence, clinical data and theory, involves patients/families in determining role responsibilities and in making decisions, offers education to the team of health care workers) American Nurses Association (ANA) Scope and Standards of Practice for Home Health Nursing 9-Evaluation: ongoing and systematic outcomes evaluation, engages the team and the patient/family to participate in the evaluation process, evaluates patient progress toward short-term goals/objectives, uses evaluation to redesign plan of care, provides results of the evaluation to patient/family and health care team members 10. Ethics 11- Education: Continuing professional education American Nurses Association (ANA) Scope and Standards of Practice for Home Health Nursing 12- Evidence-Based Practice & Research (including use of current findings to guide clinical nursing practice, sharing research findings with health care team members/peers) 13- Quality of Practice (including documentation, participation in quality improvement initiatives, collecting quality-related data, updating guidelines/procedures to improve quality of nursing practice and patient care outcomes) 14- Communication (including assessment of patient preferences/literacy/language skills, communicating effectively with interprofessional team members) American Nurses Association (ANA) Scope and Standards of Practice for Home Health Nursing 15- Leadership (including development of conflict resolution and communication skills, serving as a preceptor for new colleagues, participation on agency committees) 16- Collaboration (including partnering with others to promote change, helps build consensus, applying negotiation skills and group process techniques with patients/families/health care team, builds teamwork) 17- Professional practice evaluation (including evaluation of own practice and identification of strengths/areas needing professional growth, offers feedback to peers on performance) American Nurses Association (ANA) Scope and Standards of Practice for Home Health Nursing 18- Resource utilization (including resources available to patient/family in implementing plan of care, delegates to team members when appropriate, advocates for enhancement of nursing practice through use of technology and additional resources, helps patient/family find services needed for care and cost/benefits/risks of decisions) 19- Environmental health (including understanding of risks related to management of supplies (e.g., syringes, needles, medications, waste), assessment of home and neighborhood for unsafe/unsanitary conditions, works to reduce environmental risks that affect health of patient/family, promotes health communities) Home Health Nursing Caregiving Wheel Locating the Client and Getting Through the Door The first step in making a home visit is finding where the person lives, which might involve telephone instructions, or a global positioning system (GPS) unit. Sometimes, nurses drive agency cars, and occasionally transportation may involve a bus, subway, boat, or airplane. When families are unstable, clients may not be staying in households designated on the nurse’s paperwork. They may have moved in with relatives or friends or be back home alone despite major care needs. Locating is especially challenging when neighbors or even family members are not cooperative, for whatever reason. Locating the Client and Getting Through the Door Always remember that you are a guest in the home. Respect and attentive listening The nurse must take into account the spiritual, cultural, and developmental, as well as environmental, realms of the client in order to be able to develop individualized plans of care to promote health The home health nurse is aware that the client is the driver of the plan of care. The nurse must develop a therapeutic relationship The nurse must emphasize positives to the extent possible, rather than telling people what they are doing wrong Locating the Client and Getting Through the Door The nurse must be up front and truthful regarding the medical and nursing problems that need resolution. For example: a nurse might say, “You might lose your foot if we cannot work together to figure out a plan of care that you can live with. Let’s think together about what we can do to prevent it.” Hub of the Family Caregiving Wheel: Promoting Self- Management Home health nursing involves home visits to promote independence rather than dependence on the home health team. The challenge to the home health nurse is often assisting the severely chronically ill client be able to adapt in the community to be safe and functional. Health improvement is only possible when the home health nurse works with the client/family to make decisions that are truly their own. Hub of the Family Caregiving Wheel: Promoting Self- Management Coordination with other professionals must often be instituted to provide comprehensive quality care. Doctors, dieticians, social workers, clergy, physical therapists occupational therapists, as well as mental health professionals… The home health nurse must utilize interprofessional collaboration to agency social workers to mobilize resources to care after the agency leaves. Rim of the Home Health Caregiving Wheel: Detecting Nurses in the home are challenged by an extraordinarily complex environment Detecting is a continuing assessment process as the nurse seeks to understand the client’s health in the context of home. ❖Who lives in the home? ❖How do they interact? ❖Who are the caregivers, and how do they care? ❖What is the relevance of culture and religion in the life of the household? ❖How does the physical environment impact patient safety and security? Example: Case: the client whose refrigerator no longer chills and whose impaired vision prevents awareness of the expanding family of roaches in the kitchen. Upon each visit the nurse is assessing: 1- Client safety: Is the client in a safe environment where the outcome can be reached? Are there safety devices available for client safety? Are essential services (food, power, water, housing, security) available and sufficient for the client to function safely independently in the home? Example: Case: the client whose refrigerator no longer chills and whose impaired vision prevents awareness of the expanding family of roaches in the kitchen. Upon each visit the nurse is assessing: 2-Caregivers: Are the caregivers attentive, knowledgeable, and willing to provide care to the client in the absence of the nurse? Is the caregiver competent in providing care? Example: Case: the client whose refrigerator no longer chills and whose impaired vision prevents awareness of the expanding family of roaches in the kitchen. Upon each visit the nurse is assessing: 3-Material resources: Does the client have the necessary material resources to support the interventions? Are the medications, dressings, and supplies accessible? Does the patient have the financial support to obtain the equipment? Spokes of the Home Health Caregiving Wheel: Collaborating, Mobilizing, Strengthening, Teaching, Solving Problems Home health nursing competencies include collaborating with multiple team members and mobilizing resources in the community that can sustain the client after discharge. The home health care nurse usually is the coordinator People learn that they can manage IV lines, safely take complex drug regimens, provide rehabilitation for loved ones after stroke, and perform countless other skills that they do not believe possible until a nurse shows them and they discover that they can do it themselves. Spokes of the Home Health Caregiving Wheel: Collaborating, Mobilizing, Strengthening, Teaching, Solving Problems The home health nurse is constantly teaching clients and/or family caregivers Health coaching, also called motivational interviewing, is useful. Instead of telling people what to do, this involves asking people how they would like to change For instance: “What worries you the most?” Those concerns and relevant feelings must be validated, and the nurse leads the person to consider options for change. The solution develops through a mutual, participatory process. Ultimately, people are responsible for their own health decisions Spokes of the Home Health Caregiving Wheel: Collaborating, Mobilizing, Strengthening, Teaching, Solving Problems The home health nurse must often be creative in obtaining supplies and adjusting to conditions in the home. For example: How do patients and families with no running water wash their hands before providing care, such as dressing changes? This may lead the home health nurse to contact social agencies to provide services or teach the patient and family the use of alcohol-based gels to clean their hands. The home health nurse must be nonjudgmental, but work with the patient and family to help them understand the need to keep areas clean. Nursing Challenges in the Home INFECTION CONTROL MEDICATION SAFETY RISK OF FALLİNG TECHNOLOGY AT HOME NURSE SAFETY Infection Control Nurses are challenged to consider how to protect the home health care team, family, and community from a client with contagious disease. In such cases, all people living in the home will need instruction. Some households have inadequate facilities to control disease transmission. no access to running water, no heating unit to boil equipment, or inadequate facilities to dispose of contaminated equipment. These conditions necessitate the development of creative solutions to control infection. Infection Control Complexities of the home environment require the nurse to carefully consider exactly how microorganisms are likely to exit the body, how might they be transmitted, and how are they likely to enter the body of another individual. Medication Safety The home health client taking multiple medications is at particular risk of multiple errors in self-administration, including incorrect medication, dose, time, interval, or route. Often, doses are missed or doubled. Clients may discontinue a drug or not complete the full course. In a study, 38% of 3,124 home health patients were taking at least one potentially inappropriate medications (Bao et al, 2012). Medication Safety Prescriptions may have originated from several providers over time and may have contradictory side effects. Although weekly medication organizers can helpfully put medications in order, they can also confuse new or impaired users. Distraction, visual impairment, forgetfulness, depression, and cognitive impairment are noncompliance… common causes of unintentional medication Medication Safety The home health nurse investigates how the medication is taken by reviewing and reconciling the current list of medications and having the patient explain and demonstrate the process he goes through. Intervention requires: ❖clear and repeated instruction, ❖updating the medication list, ❖charting or diagramming the schedule for medication taking, ❖assuring that the client or caregiver knows how to use the medication box. Risk of Falling Falls are a serious issue especially for the elderly. Functional characteristics, polypharmacy, and health conditions are associated with increased rates of falls among home care clients. Clients should be observed as they move through their home and carry out activities of daily living. Home care clients require environmental adjustments in their home to reduce or eliminate the possibility of falling. Technology at Home Home health nurses teach patients and their family to manage a wide array of complex technologies. Home regimens often require mini-intensive care units. The household becomes home to dialysis, ventilators, isolation suites, enteric and IV nutrition, and vasopressors Nurses teach clients and families to manage it all Medical devices have caused injuries and deaths, so careful instructions on use in the home and oversight are needed Nurse Safety Home health nurses face risks not only dealing with driving to their client’s homes but also because of environmental hazards: the nurses must be constantly aware of personal safety and surroundings. Nurses may face instances of family violence, illegal drug activity, or weapons may be present. References Bao, Y., Shao, H., Bishop, T. F., Schackman, B. R., & Bruce, M. L. (2012). Inappropriate medication in a national sample of US elderly patients receiving home health care. Journal of general internal medicine, 27(3), 304–310. https://doi.org/10.1007/s11606-011-1905-4 Manis, D.R., McArthur, C. & Costa, A.P. (2020). Associations with rates of falls among home care clients in Ontario, Canada: a population-based, cross-sectional study. BMC Geriatr 20, 80. https://doi.org/10.1186/s12877-020-1483-6 Megido, I., Sela, Y. & Grinberg, K. (2023). Cost effectiveness of home care versus hospital care: a retrospective analysis. Cost Eff Resour Alloc, 21, 13. https://doi.org/10.1186/s12962-023-00424-0 National Research Council (US) Committee on the Role of Human Factors in Home Health Care. (2010). The Role of Human Factors in Home Health Care: Workshop Summary. Washington (DC): National Academies Press (US); Available from: https://www.ncbi.nlm.nih.gov/books/NBK210063/ OECD (2024), Old-age dependency ratio (indicator). doi: 10.1787/e0255c98-en (Accessed on 07 January 2024) Rector, C. (2018). Community and public health nursing : promoting the public’s health. Wolters Kluwer World Health Organization (WHO). (2024). Life expectancy at birth (years). https://www.who.int/data/gho/data/indicators/indicator-details/GHO/life-expectancy-at-birth-(years) THE OMAHA SYSTEM Dr. Meryem ERCEYLAN The Omaha System ◦ The Omaha System is a research-based, comprehensive practice and documentation standardized taxonomy designed to describe client care. ◦ Users are increasingly diverse, and represent the continuum of care in practice, education, research, and community settings. The Omaha System ◦ There are more than 22,000 individuals used the Omaha System in the United States and around the World ◦ The number and type of software developers who offer computerized versions of the Omaha System continue to grow. History ◦ Work on the Omaha System began in the 1970s when Visiting Nurse Association (VNA) of Omaha (Nebraska) staff began revising their home health and public health client records and adopting a problem-oriented approach. ◦ The goal was to provide a useful guide for practice, a method for documentation, and a framework for information management. History ◦ Between 1975 and 1986, three research projects were conducted to develop and refine the Omaha System. ◦ Between 1989 and 1993, further research designed to establish reliability, validity, and usability was conducted. ◦ During the early years, information was disseminated through workshops and speeches. ◦ The first Omaha System article was published in 1981, ◦ The first books in 1992, and the current book in 2005. The Omaha System The American Nurses Association recognized the Omaha System as a standardized terminology to support nursing practice in 1992. In 2014, Minnesota became the first state to recommend ANArecognized point-of-care terminologies be used in all Electronic Health Records (EHRs). Potential benefits: increased efficiency and quality outcomes; improved ability to avoid adverse events; and timely access to information from your patients’ other providers. The Features of The Omaha System It is a research-based, comprehensive, standardized taxonomy or classification 01 It is designed to enhance practice, documentation, and information management It is intended for use across the continuum of care for individuals, families, and communities 02 03 It provides a structure to document client needs and strengths, describe multidisciplinary practitioner interventions, and measure client outcomes. It supports quality improvement, critical thinking, and communication. 04 The Omaha System Consists of three relational, reliable, and valid components designed to be used together: Problem Classification Scheme (client assessment) Intervention Scheme (care plans and services) Problem Rating Scale for Outcomes (client change/evaluation) Problem Rating Scale for Outcomes Intervention Scheme Problem Classification Scheme Problem Rating Scale for Outcomes 1-Problem Classification Scheme ◦ It provides a structure, terms, and system of cues and clues for a standardized assessment of individuals, families, and communities. ◦ It helps practitioners collect, sort, document, classify, analyze, retrieve, and communicate health-related needs and strengths. ◦ It is a comprehensive, orderly, non-exhaustive, mutually exclusive taxonomy or hierarchy. ◦ The Problem Classification Scheme consists of four levels of abstraction: Four domains 42 client problems Problem modifiers Signs and symptoms Level 1: Four domains Environmental: 4 problems Psychosocial: 12 problems Physiological: 18 problems Health Related Behaviors: 8 problems Domains and Problems of the Problem Classification Scheme Environmental Domain: Material resources and physical surroundings both inside and outside the living area, neighborhood, and broader community (4 problems). Income Sanitation Residence Neighborhood/workplace safety Domains and Problems of the Problem Classification Scheme Psychosocial Domain: Patterns of behavior, emotion, communication, relationships, and development (12 problems). Communication with community resources Social contact Role change Interpersonal relationship Spirituality Grief Mental health Sexuality Caretaking/parenting Neglect Abuse Growth and development Domains and Problems of the Problem Classification Scheme Physiological Domain: Functions and processes that maintain life (18 problems). Hearing Vision Speech and language Oral health Cognition Pain Consciousness Skin Neuro-musculo-skeletal function Respiration Circulation Digestion-hydration Bowel function Urinary function Reproductive function Pregnancy Postpartum Communicable/infectious condition Domains and Problems of the Problem Classification Scheme Health-related Behaviors Domain: Patterns of activity that maintain or promote wellness, promote recovery, and decrease the risk of disease (8 problems). Nutrition Sleep and rest patterns Physical activity Personal care Substance use Family planning Health care supervision Medication regimen Level 2: 42 client problems Level 3: Problem modifiers -health promotion, potential, and actual -individual, family, and community. (whose problem?) Level 4: Signs and symptoms (describe actual problems) 2-Intervention Scheme ◦ designed to describe and communicate multidisciplinary practice, practice that is intended to prevent illness, improve or restore health, decrease deterioration, and/or provide comfort before death. ◦ describes health-related care plans and services for individuals, families, and communities. Level 1: Categories Level 2: Targets Level 3: Client-specific information Level 1: Categories Categories: ◦ Teaching, Guidance, and Counseling: Activities designed to provide information and materials, encourage action and responsibility for self-care and coping, and assist the individual/family/community to make decisions and solve problems. ◦ Treatments and Procedures: Technical activities such as wound care, specimen collection, resistive exercises, and medication prescriptions that are designed to prevent, decrease, or alleviate signs and symptoms of the individual/family/community. ◦ Case Management: Activities such as coordination, advocacy, and referral that facilitate service delivery, improve communication among health and human service providers, promote assertiveness, and guide the individual/family/community toward use of appropriate resources. ◦ Surveillance: Activities such as detection, measurement, critical analysis, and monitoring intended to identify the individual/family/community's status in relation to a given condition or phenomenon. Level 2: Target 3- The Problem Rating Scale for Outcomes ◦ The Problem Rating Scale for Outcomes is a method to evaluate client progress throughout the period of service. ◦ It is three five-point, Likert-type scales ◦ It provides to measure severity for the concepts of Knowledge, Behavior, and Status 3- The Problem Rating Scale for Outcomes 3- The Problem Rating Scale for Outcomes When is it used? Admission Interim Discharge Knowledge What client knows? The aim of using the Problem Rating Scale: assessing a client's needs, determining priority interventions assessing any changes in client care Behavior What the client does? Status How the client is? Example: Problem: Respiration Modifiers: Individuals and Actual Sign/symptom: Abnormal breath sounds Concepts 1 2 3 4 5 Knowledge Doesn’t know about breathing exercises Willing to learn about breathing exercises Describes some steps of breathing exercises Describes steps of breathing exercises Superior knowledge Behavior Unwilling to use inhalers Not using but willing to learn Uses inhalers but inconsistent technique Sometimes uses inhaler with reasonable technique Uses inhaler as recommended Status Respiration rate above 40 per minute Shortness of breath, cannot climb stairs A few crackles throughout lungs Short breath in moderate exercise, lungs clear No shortness, normal lungs sounds REFERENCES ◦ Martin, K. S. (2005). The Omaha system: A key to practice. Documentation, and information management ( 2nd ed.). Omaha Nebraska: Health Connection Press. ◦ The Omaha System. https://www.omahasystem.org/ Thank you for your attention