Chapter 30: Here is an experience I've had with [insert topic here]. Followed by a few supporting sentences that illustrate your experience.
Chapter 31: I was curious about [insert topic here]. I found this short video on YouTube that talks about [very brief summary]. Insert hyperlink here.
Chapter 32: This is something in my community that I would (or have) recommended as a resource. They do X, Y, Z. Insert hyperlink here.
Chapter 33: I researched this [insert job description]. Here's what I found about the required education, job opportunities, and potential wages.
*The examples above are NOT prescriptive and can be used in any order if you choose these prompts. These are just some formats that I think might be interesting. Please choose whatever catches your interest and write up a little something about it for the sake of discussion.
Chapter 31
Older Adults
1
Objectives
3
Identify statistics related to aging in the United States.
01
Describe mental health disorders that may occur in older adults.
02
Discuss the importance of pain assessment and tools used to assess pain in older adults.
03
Explain the negative impact of ageism that is evident in discriminatory labels, public policy, and research.
04
Case Study
Mr. Nixon is being admitted to a short-term care facility because his wife, who had been his only caretaker, has recently died. His son, who lives about 250 miles away, has been staying with him for the past 4 weeks, but has to go home now to go back to work.
Mr. Nixon has COPD and has trouble getting around because he gets short of breath. He is still grieving, of course, but his son shares that he feels his dad has been depressed over his health “off and on” as well. You will be doing an intake assessment with Mr. Nixon.
4
Statistics on Aging
5
Life expectancy and number of older adults growing
Common classifications for older adults:
Young-old: 65 to 74 years
Middle-old: 75 to 84 years
Old-old: 85 to 100 years
Centenarians: 100 to 104 years
Mental Health and Aging
6
Late-life Mental Illness
Major Depressive Disorder
Suicide
Anxiety disorders
Delirium—secondary to general medical condition
Neurocognitive disorders
Alcohol use disorder
Pain
Pain
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Nonpharmacological treatments for pain include physical therapy, vagal nerve stimulation, exercise, hydrotherapy, heat and cold packs, chiropractic, and transcutaneous electrical nerve stimulation (TENS).
Yoga, biofeedback, hypnosis, acupuncture, massage, Reiki, guided imagery, reflexology, and therapeutic touch are integrative therapies for managing pain.
Herbal remedies include cayenne, capsaicin, ginger extract, echinacea, kava, and willow bark.
7
Barriers to accurate pain assessment
Assessment tools
Wong-Baker FACES Pain Rating Scale
Pain Assessment in Advanced Dementia (PAINAD) scale
Pain management
Pharmacotherapy
Non-opioids
Opioids
Nonpharmacological pain treatments
Healthcare Concerns of Older Adults
Financial burden
Medicare Part D for help with medications
Caregiver burden
Ageism
Language
Public policy
Research
This Photo by Unknown author is licensed under CC BY-NC-ND.
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Discussion Topic
Ageism sometimes affects the care of older adult patients. The best way to help prevent this is to do a self-assessment and discuss your feelings and attitudes with others: What kinds of feelings, assumptions, or hesitations do you have when you think about working with an older adult?
9
Healthcare Decision-Making
Advance Directives and Portable Medical Orders
Advance Directives and Portable Medical Orders
Guardianship
Court-ordered relationship in which the selected guardian acts on behalf of another individual (the ward)
The ward must be proven to lack capacity to manage personal and/or financial affairs
This Photo by Unknown author is licensed under CC BY-NC-ND.
10
Objectives
11
Explain the importance of a comprehensive assessment in older adults.
1
Recognize the significance of healthcare costs for older adults.
2
Compare the facts and myths about aging.
3
Analyze how ageism may affect attitudes and willingness to care for older adults.
4
Apply the nursing process to the care of older adults.
5
Objectives
12
Identify at least four priority nursing diagnoses in the care of older adults.
1
Discuss basic nursing interventions in the care of older adults.
2
Identify psychological therapies used in the treatment of older adults.
3
Identify treatment settings for the care of older adults.
4
Application of the Nursing Process
Assessment
Private interview space
Adequate lighting & low-level noise
Establish rapport & convey warmth
Physical Assessment
Medication reconciliation
Polypharmacy & prescribing cascades
Mental Status exam
Older adult drivers
Older adult abuse
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Assessing the use of multiple medications for the same condition (polypharmacy) includes prescription, over-the-counter drugs, and herbal agents. Adverse drug reactions or negative responses to drugs are common among the older adult.
Prescribing cascades happen when drug-induced symptoms are treated with another drug. The provider may assess the side effect of the first drug as part of the original medical problem or a new one.
13
Case Study Discussion Question
You are preparing to interview Mr. Nixon. What are some techniques the nurse could use to help the patient feel more comfortable?
Conducting the interview in a private area
Introducing oneself and asking the patient what he or she would like to be called (use of the first name is rarely appropriate unless one is invited to do so)
Establishing rapport and putting the patient at ease by sitting or standing at the same level as the patient
Ensuring that lighting is adequate and noise level is low, in recognition of the fact that hearing and vision may be impaired
Using touch (with permission) to convey warmth, while at the same time respecting the patient's comfort level with personal touch
Summarizing the interaction, inviting feedback and questions, and thanking the patient for giving his or her time and information
14
Quick Quiz
Mr. Nixon, who has difficulty walking because of shortness of breath secondary to COPD says, “Every day is a struggle when you get old. No one cares about old people.” Select the best response.
“Rest periods are important. Don’t try to overexert yourself.”
“It sounds like you’re having a difficult time. Tell me about it.”
“Let’s not focus on the negative. Tell me something good.”
“You are still able to get around, and your mind is alert.”
ANS: B
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Nursing Diagnosis
The International Classification for Nursing Practice (ICNP) (International Council of Nurses)
Provides useful nursing diagnoses for older adults
Acute/chronic pain, impaired low nutrition intake, impaired fluid intake, constipation, and impaired sleep
Safety needs
Higher level needs
Caregiver stress/impaired family process
Outcomes Identification
Shared decision making; realistic goals
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Some essential safety diagnoses include risk for injury, risk for falls, impaired ability to manage medication regime, victim of older adult abuse, and confusion.
Higher level needs fall under Maslow’s categories of love and belonging needs, and esteem. Specific (ICNP) nursing diagnoses address those higher-level needs such as loneliness, hopelessness, impaired role performance, chronic low self-esteem, and disturbed personal identity.
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Implementation
Psychotherapeutic Methods
Empathetic, active listening to encourage ventilation of feelings & reestablish emotional equilibrium
Provide health education & alternatives
Assist in problem solving
Group counseling to help build relationships and reduce isolation
Pharmacotherapy skills & psychotherapy
Treatment Modalities
Psychological Therapies
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Reminiscence is a cognitive stimulation activity that engages individuals in socialization and rapport building. Assisting to evoke pleasant feelings or memories is an effective method to improve mood, particularly in those with memory impairment.
17
Case Study
Mr. Nixon’s son drives back down the next weekend so they can meet to talk about his options for a more permanent living situation. As part of this process, the son has made an appointment for the two of them to meet with the nurse, who can help them explore their options.
His son asks, “So what kinds of choices does Dad have at this point?”
18
Treatment Settings for Older Adults
This Photo by Unknown author is licensed under CC BY-SA.
19
Hospital-Based Care
Partial hospitalization versus Inpatient
Home-Based Services
Day care programs
Home healthcare
Community support services
Respite care
Residential Care
Assisted living
Skilled nursing facilities
Case Study
Mr. Nixon’s son heads for home again and says, “I’ll be back again next weekend, Dad. Keep thinking about what sounds good to you. You can call me any time.” Mr. Nixon feels a little better about his future, but says, “It’s just a lot to think about. The nurse suggests that Mr. Nixon might benefit from group sessions with others who are trying to make similar plans. This may not only aid in decision making but help him to feel less alone in this big next step.
20
Quick Quiz
A community mental health nurse plans an educational program for the staff of a home health agency specializing in care of the elderly. A topic of high priority should be
identifying clinical depression in older adults.
identifying nutritional deficiencies in the elderly.
providing cost-effective foot care for the elderly.
psychosocial stimulation for those who live alone.
ANS: A
21
Case Study & Quick Quiz
Mr. Nixon needs help with his prescription ordering. Which component of Medicare assists seniors to pay for prescription drugs?
Part A
Part B
Part C
Part D
ANS: D
22
Quick Quiz
A family member of a patient with advanced dementia says to the nurse, “I will sign the consent for my mother’s surgery.” What is the nurse’s best response?
“This should be a family decision. When will your siblings arrive?”
“Can you please show me the Court order designating you as guardian?”
“Thank you. Please use a black ballpoint pen to sign.”
“The patient is able to sign her own consent.”
ANS: B
A guardianship is a court-ordered relationship in which one party, the guardian, acts on behalf of an individual, the ward. Many people with mental illness, mental retardation, traumatic brain injuries, and organic brain disorders, such as dementia, have guardians. It is important that health care workers identify patients who have guardians and communicate with the guardians when health care decisions are being made.
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1
Objectives
3
Describe
Describe the evolution of life-saving measures and their impact on end-of-life issues.
Discuss
Discuss the role of palliative care and hospice in supporting patients and families facing chronic diseases and terminal illnesses.
Identify
Identify stages of the dying process as described by Kübler-Ross.
Objectives
4
Discuss the following topics regarding death: artificial nutrition and hydration, euthanasia, and legally assisted suicide.
Describe the components of advance care planning for death.
Death and Dying
Advances in technology have blurred the line between life and death
Artificial nutrition and hydration
Artificial breathing and blood filtering
Transplants
An aging population
Unprecedented strains on healthcare system
This Photo by Unknown author is licensed under CC BY-ND.
5
Models for End-of-Life Care
Hospice
Standard for care for patients facing death
Begins after treatment has stopped
Begins when it is clear survival is not possible
Focus: patient care and symptom reduction
Palliative Care
Promotes comfort
Can begin at time of diagnosis
Focus: care for people living with serious illness
This Photo by Unknown author is licensed under CC BY-NC-ND.
6
Unlike hospice care palliative care can begin at the time of diagnosis and continue throughout the treatment of the illness. For palliative care people may or may not be terminally ill to benefit.
Key Components of Both Models
7
Honoring patient and family experiences
01
Respecting autonomy and informed choice
02
Allowing directing of care by patient (and family)
03
Honoring the dignity of the patient and family
04
Case Study
Mr. Dietrich has found out he has terminal brain cancer. At first he and his wife just can’t believe it’s true. They leave the doctor’s office silent and stunned, holding hands. They drive home in silence, but stop to get their mail as usual, pick up some fast food, as they always do on a Wednesday.
At home that night, he pops popcorn while she sets up the movie they’ve chosen. She looks at him and smiles. “Look at your appetite,” she says. “It’s wonderful! You don’t have brain cancer.”
“I think you’re right,” he smiles and squeezes her hand.
8
Kübler-Ross’s 5 Stages
9
Denial and isolation
Anger
Bargaining
Depression
Acceptance
Facilitating Death
Artificial Nutrition and Hydration
Not a comfort measure
Euthanasia
Legally Assisted Death: Relevant Arguments
Individual liberty
Autonomy
Quality of care
Nonmaleficence
Beneficence
This Photo by Unknown author is licensed under CC BY-ND.
Supplementation of food and water is not a comfort measure and is therefore not a component of basic care for the actively dying. It does not generally benefit people who are actively dying. In fact, providing artificial hydration by such means as intravenous fluids can increase edema, pulmonary congestion, ascites, nausea, and vomiting. Generally, the unwillingness or inability to eat and drink is caused by the impending death of the patient.
10
Advance Care Planning
Advance directives
Statement of how you want medical decisions to be made if you cannot make them yourself
Durable power of attorney for health care
Living will
Provider orders for life-sustaining treatment (POLST)
Based on the patient’s preferred code status in the case of cardiopulmonary arrest
This Photo by Unknown author is licensed under CC BY.
Since the 1960s, people have increasingly sought to participate in decision making about healthcare. In 1990 Congress passed the Patient Self-Determination Act (PSDA) (1990) requiring that healthcare facilities provide clearly written information for every patient including legal rights to make healthcare decisions, especially the right to accept or refuse treatment. The PSDA also establishes the right of a person to provide directions, or advance directives, for clinicians to follow in the event of a serious illness.
11
Case Study
Mr. and Mrs. Dietrich meet with the hospice nurse after three weeks of adjustment.
“We’d like help with advance care planning,” Mr. Dietrich says. His wife nods and holds his hand, trying not to cry. “We don’t want him to suffer. That’s my main concern. If he can’t survive this, I just don’t want him in pain or throwing up a lot, things like that.” She starts to cry, and he gives her shoulder a squeeze.
12
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