STUDY GUIDE for C475 Care of Older Adult Objective Assessment / Exam questions are taken from the Learning Objectives under the 9 Competencies / Download To Score A.

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STUDY GUIDE for C475 Care of Older Adult Objective Assessment Exam questions are taken from the Learning Objectives under the 9 Competencies: #1 Competency 742.1.1: Compassionate and Respectful ... Care of Older Adults The graduate integrates principles of compassion and respect for patients and their families into the planning and delivery of care to a diverse population of older adults and into advocacy for vulnerable older adults. This topic addresses the following learning objectives: • Recognize the impact of attitudes, values, and expectations about aging. • Describe how the RN’s personal beliefs and values may impact the care of older adults. • Articulate the concept of individualized care as the standard of practice with older adults, considering the right care, at the right time, in the right place and by the right provider of care. ➢ Define Baby Boomers ▪ Those born between 1946-1964; that are now reaching retirement age ➢ What are the five racial groups listed in your text? ▪ European Americans, African Americans, Hispanic Americans, Asian Americans, and Native Americans ➢ How would you perform discharge teaching to an Hispanic patient ▪ Whittemore (2007) conducted a systematic review of the literature to identify culturally competent interventions for Hispanic adults with type 2 diabetes. In reviewing 11 studies, Whittemore found that providing educational sessions and written materials, in both English and Spanish; employing bilingual Hispanic staff; including family members in an informal atmosphere in health care encounters; incorporating cultural traditions in interventions; developing culturally relevant program literature; and providing fact sheets about risk and potential poor outcomes of chronic conditions such as diabetes will increase the effectiveness of interventions. • Apply effective and respectful communication strategies in the care of older adults and their families. ➢ List some of the changes of aging that could affect therapeutic communication ▪ Physical: like aphasia (difficulty finding words, writing, expression), dysarthria (difficult speaking) ▪ Psychological: Dementia, Mental disease, schizophrenia, depression, embarrassment (hearing loss, vision loss), English as a second language (cannot understand or relay message) , fear of being labeled as a complainer ▪ Eyes: Senile miosis, difficulty adjusting to bright lights, presbyopia (accomodating near to far), decrease in acuity or depth perception, dry eyes ▪ Ears: conduction problems, tumors, infections, foreign objects, noise pollution (hx playing in band), otoxic substances, freq, presbycuspis most common ** ➢ Note the ways to communicate or assist a patient with disabilities such as hearing deficits, vision impairments, or aphasia and dysarthria. How should you address the older adult during therapeutic communication? ▪ Disabilities in general: Slow down, allow time for reaction, set up environment, gather supplies ahead of time, tell family members to answer only when directed, introduce your name and role, eliminate background noise (turn off tv if too loud), determine how the pt likes to be addressed (never use honey or dear), extend your hand and shake and smile, maintain eye contact, do not talk down, avoid crossing arms, do not minimize their concerns ▪ Hearing loss: Do not use a high pitch voice or shout, stand in front of them, Sit at the side they hear best, Do not cover your face, Eliminate background noise ▪ Visual loss: Do not startle, position yourself, provide ample lighting, be prepared if the patient states they see objects that you do not. ▪ Language impairment: use short, uncomplicated sentences, maintain eye contact, provide an environment low in distractions, observe facial cues, paper and pen, do not correct what they say. ➢ Know the abbreviations or acronyms, such as AAC. Know which hearing aids cover the widest range of hearing loss. See the box on Types of Hearing Aids in chapter 5. Both hearing aids and AAC will be mentioned again in Chapter 16. -AAC ‘augmented and alternative communication’, is an integrated group of components, including symbols, aids, strategies and techniques used by individuals to enhance communication. -BTE (behind the ear) is the most common and covers the widest range of hearing loss assistive device. ➢ Make sure you understand what patients could benefit from the use of the AAC. ▪ Deaf, Dysarthria ➢ Understand what things can occur to make it difficult to communicate ▪ Any barriers listed above, embarrassment, isolation, etc. ➢ Which type of hearing aid covers the entire range of hearing loss? Behind the ear, functions on battery, easy to use. ➢ What factors in a diverse aging population affect communication? • Support individual health goals that range from healthy activities to simply achieving comfort. • Illustrate compassionate and individualized care for older adults with chronic illness that reduces symptom burden and seeks to preserve quality of life. #2 Competency 742.1.2: Health Promotion/Maintenance and Living Environments of Older Adults The graduate evaluates the older adults' life world with special awareness of the diversity among the health status of older adults, individualizing care according to the physical, mental/cognitive, functional, and psycho-social well-being of an elder patient, along with support systems in place. *You will notice that Competencies two through five overlap one another. Some of the information for one topic may be found in another topic or another competency. Don’t become frustrated. It will all come together. This topic addresses the following learning objectives: • Identify functional and physical changes in the aging adult that would necessitate changes to the living environment. • Identify cognitive, psychological, and social changes common to the aging adult that would necessitate changes to the living environment. • Recognize steps to mitigate common physical safety issues. • Analyze the living environment of a given older adult with special awareness of the functional, physical, cognitive, psychological, and social changes of aging. ➢ What are the five A’s to tobacco cessation? ➢ What are the Five R’s to tobacco cessation? ✓ The 5 As ✓ Ask about smoking status at each health care visit. ✓ Advise client to quit smoking. ✓ Assess client’s willingness to quit smoking at this time. ✓ Assist client to quit using counseling and pharmacotherapy. ✓ Arrange for follow-up within one week of scheduled quit date. ✓ The 5 Rs ✓ Relevance: Ask the client to think about why quitting may be personally relevant for him or her. ✓ Risks of smoking are identified by the client. ✓ Rewards of quitting are identified by the client. ✓ Roadblocks or barriers to quitting are identified by the client. ✓ Repetition of this process at every clinic visit. Most people who successfully quit smoking require multiple attempts. ➢ What is the criterion for the pneumococcal vaccine? ✓ Pneumococcal vaccine is given once for clients who are 65 years of age or older. There is evidence to support one-time-only revaccination for clients 75 years or older who have not been vaccinated in 5 or more years. ➢ In most cases of elder abuse who is the perpetrator? ✓ Most cases of elder abuse are perpetrated by a family member, and reasons for the abuse include caregiver burnout and stress, financial worries, transgenerational violence, and psychopathology in the abuser. Women and dependent elders tend to be the most vulnerable to abuse. ➢ What 5 areas do Healthy People 2010 and the USPSTF suggest that nurses focus on to promote health & prevent disability in the older adult? (see page 356 in text) ✓ Physical activity ✓ Nutrition ✓ Tobacco use ✓ Safety ✓ Immunization ➢ Describe the difference between ADLs and IADLs (instrumental activities of daily living) ✓ ADL: Include bathing, dressing, grooming, showering, and toileting activities. ✓ IADL: Activities related to independent living; they include meal preparation, money management, shopping, housework, and using a telephone. ✓ Tools of ADL/IADL can be used to determine functional ability of a pt and how much they need to depend on others to live alone or with some assistance. ➢ List the nutritional assessment tests to determine risk for diet-related chronic illness (see text page 359) ✓ DETERMINE Your Nutritional Health Checklist: A tool created by the Nutrition Screening Initiative, a collaborative project of health, medical, and aging organizations. The nutrition checklist can be ordered from the initiative’s Web site for a nominal fee. ✓ • Serum albumin: Less than 3.5 g/dl is associated with malnutrition and increased morbidity and mortality. ✓ • Body mass index (BMI): The Nutrition Screening Initiative suggests that a BMI of 22–27 is considered normal. Values above or below this range suggest over- and underweight, respectively. Unintended weight loss is a nutritional risk that requires additional assessment. Obesity is a problem for many older Americans, just as it is for younger adults. The Obesity Education Initiative of the National Heart, Lung, and Blood Institute (2005) has provider guidelines and patient education materials ✓ • Adult Treatment Panel (ATP III) Cholesterol Guidelines: An unintended decrease in cholesterol to less than 150 mg/dl is a nutritional risk ✓ • ADL and IADL measures: These can assess a client’s ability to eat and prepare food and to do the shopping and transportation necessary for good nutrition. ✓ • Dietary Reference Intakes and Recommended Daily Allowances: These can be compared with food diaries from a 24- to 48-hour period to assess marked deviation from these guidelines. Clients who use many vitamin and nutritional supplements may be at risk for toxicities. ✓ • Depression and dementia: Both are risk factors for nutritional compromise. ➢ Review the USPSTF Screening Recommendations for Older Adults, Table 12-1 on page 376 in text. ✓ Immunizations: ▪ Annual flu vaccine ▪ Pneumococcal vaccine once after age 65 and onetime revaccination for clients over age 75 who’ve not been vaccinated in 5 years ▪ Td vaccine every 10 years ➢ Review the I HATE FALLING risk assessment tool, Box 12-4 on page 361. What can the nurse recommend to reduce risk of falling? ✓ Inflammation of joints or joint deformity ✓ Hypotension (orthostatic blood pressure change) ✓ Auditory and visual abnormalities ✓ Tremor ✓ Equilibrium problems ✓ Foot problems ✓ Arrhythmias, heart block, valvular disease ✓ Leg-length discrepancy ✓ Lack of conditioning (generalized weakness) ✓ Illness ✓ Nutrition (poor, weight loss) ✓ Gait disturbance ➢ Balance and strengthening exercises, home safety modifications, and elimination of high-risk medications have been the focus of fall-risk prevention strategies. There are strong data to support the effectiveness of balance and strengthening exercises for fall reduction, as well as research to support physiologic and environmental risk factor reduction. PREVENTION is key. #3 Competency 742.1.3: Health Needs of Older Adults The graduate effectively collaborates with patients, families and inter-professional team members in planning primary, secondary, tertiary and end-of-life care that addresses older adults' physical, mental, psychosocial and spiritual needs and preferences and responses to changes in health status and related treatments. This topic addresses the following learning objectives: • Identify how the physiological changes of aging affect the organs involved in absorption and excretion of medications • Recognize functional changes and mobility issues that may threaten independence in the older adult. • Identify factors that may contribute to alterations in nutrition, metabolism, and elimination in older adults. • Recognize the signs and symptoms of geriatric syndromes and the subsequent frailty that may result. • Apply knowledge of the aging process and associated risk factors; skills in history-taking and assessment; and respect for the dignity of older adults in a comprehensive, individualized assessment. • Identify and use valid and reliable standardized tools of functional assessment in older adults. • Identify and use valid and reliable standardized tools of cognitive assessment in older adults. • Observe for risks or the presence of the five most common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, and delirium, including hypokinetic delirium). • Compare specified theories of aging, including the genetic theory. • Describe how to use evidence-based assessment tools and methods to conduct a comprehensive assessment of an older adult. • Promote quality outcomes through the application of evidence-based practices specific to the care needs of older adults. • Promote evidence-based practice by utilizing the Beer list of potentially unsafe medications for the elderly. • Contribute to interdisciplinary plans of care to promote health, reduce risk, and prevent disease in older adults. • Contribute to interdisciplinary care plans that address common acute and chronic health conditions, such as arthritis, diabetes, cardiovascular diseases that may lead to congestive heart failure, and dementia. • Consider potential drug side effects in assessing adverse symptoms in older adults. ➢ There are three types of assessments: Physical, Cognitive and Functional. ✓ Physical assessment is assessing the patient’s physical health. It included vital signs, assessing for pain, blood pressure problems, irregular heartbeat, abnormal breath sounds, etc. you know these because as a nurse you are always assessing the patient. In addition, for older adults you want to assess cognitive function. ✓ Functional assessment is assessing what the older adult can still for themselves. Bathing, eating, getting dress, brushing their teeth and more are functional abilities. Functional abilities can be altered due to physical impairment and illness. Dr. Katz and Dr. Barthel developed ADL/IADL indexes to measure the patients functional abilities. You should have noticed that ADL is used throughout the book. This is because the ADL's can determine the patient's care plan. It determines whether they are safe in the current environment. It impacts their ability to participate in health promotion and disease prevention. ✓ Cognitive- thought processing, thinking and reasoning skills. Know the normal cognitive changes as a result of aging. Dementia is not normal. You will need to understand the difference between delirium & dementia. ▪ Delirium: Acute ▪ Dementia: Chronic ➢ There are special tools to assess the older adult that have been proven to produce accurate results. You must be familiar with those tools specific for the older adult. The exam will use the acronyms for the tools. For example, CAM, MMSE, CDT, SPICES. Make sure you know what these stand for and can answer when they are to be used or what the results of these assessment tools will tell you. o CAM- confusion assessment method – to assess for delirium. o MMSE- mini mental state examination—to assess cognitive function. (The most extensively used cognitive assessment tool***) o CDT- clock drawing test—used during the mini cog (draw a clock and request a certain time) o SPICES- an overall assessment tool for older adults (Sleeping, Problems with eating and sleeping, incontinence, Confusion, Evidence of falls, and skin breakdown) ➢ Be familiar with the pain assessment tools, and how unrelieved pain can lead to prolonged hospitalization. ➢ Know Katz Index of ADL and Barthel Index both are in chapter 7. You will see ADL and IADL throughout the rest of the entire book. o Katz: distinguished between independence and dependence in activities and created an ordered relationship among ADLs. It addressed the need for assistance in bathing, eating, dressing, transfer, toileting, and continence. Uses a scoring 0 for dependent and 1 for independent and helps with discharge and POC. o Barthel: This index was designed to measure functional levels of self-care and mobility, and it rates the ability to feed and groom oneself, bathe, go to the toilet, walk (or propel a wheelchair), climb stairs, and control bowel and bladder ➢ The Mini Mental State Examination (MMSE) is the most extensively used cognitive assessment tool (page 246): The MMSE was originally developed to differentiate organic from functional disorders and to measure change in cognitive impairment, but it was not intended to be used as a diagnostic tool. It measures orientation, registration, attention and calculation, short-term recall, language, and visuospatial function. ➢ The Mini-Cog can be done in 5 minutes see also www.consultgerirn.org. ➢ They may also mention CDT (Clock Drawing Test) which is commonly done with the Mini- Cog evaluation. Chapter 7 ➢ You have to know the physiological changes that occur which make the older adult more susceptible to adverse drug reactions. o Age-related alterations in drug distribution, hepatic metabolism, and renal clearance all play a significant role in the chances of an elderly patient developing an ADR. ADRs in elderly patients may decrease functional status, increase health services use, and in some rare cases have resulted in death ✓ Five Rights of Medication Administration ▪ Right Drug, Right Route, Right Dose, Right patient, Right time. ✓ The most common drugs that alter lab results: ▪ Drugs commonly used by the elderly may alter laboratory results. Isoniazid, levodopa, morphine, vitamin C, and penicillin G may lead to false-positive urine glucose results. Levodopa may produce an increase in serum bilirubin and uric acid ✓ Polypharmacy- why is the older adult more apt to polypharmacy: ▪ Many older patients are prescribed multiple drugs, take over-the- counter medications, and are often prescribed additional drugs to treat the side effects of the medications that they are already taking. Also, demented patients may not be aware of why they are taking a medication and may take an OTC that will have the same effect. ✓ Beers’ List of Inappropriate drugs for Older Adults- this is in the e-text and www.consultgerirn.org. Make sure you are familiar with this. Benzodiazepines are mentioned quite a bit. ▪ Questions to Ask to Avoid Inappropriate Prescribing for Elderly Patients: ▪ Is the treatment necessary? ▪ Is this the safest drug available? ▪ Is this the most appropriate dose, route of administration, and dosage form? ▪ Is the frequency appropriate? ▪ Do the benefits outweigh this risk? ✓ Meds: ▪ Darvon, Darvocet ▪ Benedryl ▪ Antichol’s (Amitryptline) ▪ Demerol ▪ Barbituates, Benzo’s ▪ Nifedipine (Procardia) ▪ Clonidine ▪ Flexeril, oxybutynin ▪ Dipyrmainole ▪ Indocin ➢ MAP- this means medication assistance program and it will be mentioned in a later chapter. Make sure you understand what it is. This is a choice you can offer your patient who cannot pay for their medication. ➢ You want to advise your patients to become very familiar with their pharmacist. Only use one pharmacy for all their medications, including over the counter (OTC) and herbal remedies. The pharmacist can alert the patient to potential drug reactions. ➢ Know the common classes cause ADR: antipsychotics, antihistamines, benzodiazepine (Atarax, restoril, florazepam, diazepam, Librium, Xanax, Restyl, Paxil), Muscle relaxants, anti-anxiety drugs, anti-convulsants, antiemetics, analgesics #4 Competency 742.1.4: Promoting Independence and Autonomy While Reducing Risk Factors in Older Adults The graduate recommends techniques to co-create health and illness management practices with older adults and their families (caregivers) that ensure safety and optimal maintenance of functional ability, taking into account patient characteristics and needs and patient and caregiver vulnerabilities as well as strengths. This topic addresses the following learning objectives: • Identify ethical principles for preserving autonomy while reducing risk in the care of older adults. • Describe strategies for preventing morbidity and mortality associated with the use of physical and chemical restraints in older adults. • Determine appropriate best practices to co-create a plan of care with the patient, family and other caregivers. • Explain how you would assist older adults, families, and caregivers to balance the need for autonomy and safety when making everyday decisions. • Apply ethical and legal principles to the complex issues that arise in the care of older adults. • Identify appropriate principles of care commensurate with older adults' vulnerabilities and the frequency and intensity of care needs. • Assess the effectiveness of various steps taken to assist health professionals in recognizing and reporting suspected mistreatment of older adults or abuse of resources. • Recommend appropriate individualized care practices to eliminate the use of physical and chemical restraints in older adults. • Recommend techniques to create health practices of a given older adult and family to address identified patient vulnerabilities. ➢ Define autonomy and self-determination. o Autonomy is the concept that each person has a right to make independent choices and decisions. It is reflected in guidelines and laws regarding patient rights and self-determination. Inherent in the concept of autonomy is respect for another and their decisions and that each person should be treated with dignity as a unique individual with inherent worth. o Self-determination: The right of the patient to make a choice about their outcomes and abilities. ➢ What is frailty? What are the characteristics? o Frailty is perceived as a general decline in the physical function of older adults that can increase vulnerability to illness and decline. Defining characteristics include unintentional weight loss of more than 10% in the prior year, feelings of exhaustion, grip strength in the weakest 20% for age, walking speed in the lowest 20% for age, and low caloric expenditure (<270 kcal) per week on physical activity. Neither age nor disability alone makes a person frail, but changes that often occur with age may contribute significantly to its presence. At nearly every age past 65, women commonly experience frailty at a greater percentage than men ➢ What is the Kohlman Evaluation of Living Skills (KELS)? o KELS- which has been adapted for the geriatric population and is commonly administered by occupational therapists. It assesses 17 daily living skills under five categories—self-care, safety and health, money management, transportation and telephone use, and work and leisure. ➢ What are the factors that influence the quality of life of an older adult? o Quality of life is a perception based on personal values and beliefs. Views on quality of life are widely variable and likely to change when circumstances differ. They are influenced by emotional, physical, economic, and social needs. Some quality-of-life decisions are made in direct relation to the burden being placed on others. Sometimes it is not the big things such as limitations in mobility that cause the greatest burden on quality of life, but rather the indignity and emotional burden associated with problems such as incontinence and dependency. ➢ What is the one of the most common role changes faced by the aging person? List all. o Retirement is the most common but also, health transitions (healthy to ill), loss of spouse, and role reversal (as parent to child), and not driving a car. ➢ What is role reversal for the older adult? o Role reversal with a spouse or adult children often occurs for the aging person, as the elder moves from care provider to care recipient through the course of aging. When a very strong and independent elder experiences failing health, the transition to dependency may drain the energies of both the provider and the recipient who are part of the role reversal ➢ List and describe the care options for the older adult? o • Independent living with help: Cooks, companions, homemaker/cleaning service —formal or informal. o • Family: Usually informal; may live in patient’s or family member’s home. o • Adult daycare at a facility: Part-time temporary assistance, frequently for respite or while a family caregiver works; often used for persons with dementia or for the frail elderly needing assistance or at risk for social isolation. Usual discharge is to assisted living or death. o • Adult daycare at home: Part-time respite, as above. o • Senior living complexes/continuing care/supported care retirement communities: Full range or limited services, depending on the community and level of assistance needed; can be progressive as needs increase. o • Assisted living: Homelike setting with more physical and medical care available than in senior complexes. o • Paid caregiver homes (licensed or unlicensed): Caregivers accept one or several nonrelatives into their home to receive 24-hour assistance, especially with BADLs, usually on a private-pay basis. In some states, public subsidies may cover adult group/foster home care. o • Extended care facilities: Skilled or intermediate care nursing home facilities for rehabilitation or ongoing care; can be paid by Medicare, Medicaid, or private pay, depending on financial resources. Preadmission screening is usually required by the state regulatory agency. ➢ What is the Borg Category Rating Scale? o Allows persons to rate their own level of activity and and target their desired level of exercise. (6 being very light and 20 being very heavy) ➢ What are the common signs of abuse in an older adult and who is mostly to be the abuser? o Most cases of elder abuse are perpetrated by a family member, and reasons for the abuse include caregiver burnout and stress, financial worries, transgenerational violence, and psychopathology in the abuser. o Signs of abuse: ➢ • The presence of several injuries in different stages of repair ➢ • Delays in seeking treatment ➢ • Injuries that cannot be explained or that are inconsistent with the client’s history ➢ • Contradictory explanations by the caregiver and the patient ➢ • Bruises, burns, welts, lacerations, or restraint marks ➢ • Dehydration, malnutrition, decubitus ulcers, or poor hygiene ➢ • Depression, withdrawal, or agitation ➢ • Signs of medication misuse ➢ • A pattern of missed or cancelled appointments ➢ • Frequent changes in health care providers ➢ • Discharge, bleeding, or pain in the rectum or vagina or a sexually transmitted disease ➢ • Missing prosthetic device(s), such as dentures, glasses, or hearing aids ➢ List common tools used to assess abuse in the older adult? o The Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST) and the Vulnerability to Abuse Screening Scale ➢ Describe the Framingham Heart Study. What did it look at and what were the findings? o This study began with over 5,000 male and female subjects about 50 years ago in order to study cardiovascular risk factors. As a result of decades of epidemiologic work, the following risk factors have been identified: ➢ • Age greater than or equal to 50 for men and 60 for women ➢ • Hypertension ➢ • Smoking ➢ • Obesity ➢ • Family history of premature CHD ➢ • Diabetes (considered to be a CHD risk-equivalent, i.e., carries the same risk of a coronary event as known CHD) ➢ • Sedentary lifestyle ➢ • Abnormal lipid levels ➢ What are the risk factors for stroke? Describe the statistical data in regards to strokes and the older adult. o increased age, hypertension, smoking, and diabetes. Clients with coronary artery disease are at increased risk for stroke because atherosclerotic vessel disease is a common etiology for the two diseases. Also, heavy alcohol use, cigarette smoking, sedentary lifestyle, and a high-fat diet. In addition to these risk factors, atrial fibrillation and asymptomatic carotid stenosis place clients at high risk for cerebrovascular disease. o It is estimated that 36% of strokes suffered by clients 80–89 years of age are as a result of nonvalvular atrial fibrillation ➢ What are other disease processes the older adult is at risk for? Explain the prevalence and how to prevent or control the illness o Thyroid Disease: Overt disease affects 5% of American adults, but the prevalence of subclinical hypothyroidism (elevated thyroid-stimulating hormone [TSH] with normal levels of thyroid hormone) is 17.4% among women older than age 75 and 6.2% among men over age 65. The task force recommends that clinicians be cognizant of the signs and symptoms of thyroid disease, and test symptomatic patients; evidence is lacking to justify screening of asymptomatic patients, however. o Osteoporosis is common in the elderly and is correlated with fracture risk. There are good screening tests to diagnose osteoporosis and effective treatments for the disease o The prevalence of hearing and visual impairment increases with age and has been correlated with social and emotional isolation, clinical depression, and functional impairment. An objective hearing loss can be identified in over one- third of persons age 65 years or older and in up to half of patients age 85 years or older. o Breast cancer is the most common cancer among U.S. women, and the prevalence of the disease increases with age. According to the CDC (2008), 3–4% of women who are 60 years old today will get breast cancer by the age of 70. Both clinical and self breast examinations are rec’m. o Prostate cancer is both the second most common form of cancer among U.S. men and the second leading cause of cancer death in U.S. men. Two tests are commonly used in prostate cancer screening: the digital rectal exam (DRE) and the prostate-specific antigen (PSA) blood test. o Colorectal cancer is both the third most common cancer in the United States and the third leading cause of cancer death in the United States. The prevalence of the disease increases with age, and over 90% of colorectal cancer is diagnosed in clients over the age of 50. Colonoscopy rec’m over the age of 50. ➢ Instruct the patient to obtain all medications (prescription and nonprescription) at one pharmacy so that pharmacists can check for potentially dangerous interactions. The pharmacist can serve as the central figure who maintains a list of medications and screens for drug-drug interactions to avoid harmful situations. #5 Competency 742.1.5: Promoting Health and Independence in Older Adults. The graduate selects appropriate evidence-based standards of health promotion, risk reduction, and disease prevention in older adult populations. This topic addresses the following learning objectives: • Explain how to facilitate older adults' active engagement and participation in their own healthcare. • After discussing evidence-based health promotion activities, facilitate the development of health promotion goals with a given older adult. • Analyze evidence-based research regarding risk reduction and disease prevention in older adults. • Describe strategies to enhance the physical and mental function of older adults. • Identify common risk factors that contribute to functional decline in older adults. • Identify the principles for improving functional ability and quality of life for the older adult. • Articulate psychosocial interventions for maximizing a given older adult’s quality of life. ➢ What is the definition of a fall? o An event which results in a person unintentionally coming to rest on the ground or another lower level; not as a result of a major intrinsic event (such as a stroke) or overwhelming hazard. ➢ And what can happen to an older adult after a fall? o Falls can result in injury, loss of independence, reduced quality of life, and death in the elderly. Fractures are the most serious health consequence of falls. ➢ What are the risks for falls? (Past history of falls is a major risk factor!) o Previous falls, medications, cognitive impairment, dizziness/syncope history, heart related changes (hypotension, arrhythmias), confusion. ➢ What are intrinsic risk factors? o Intrinsic risk factors relate to the changes associated with aging and with disorders of physical functions needed to maintain balance. These functions include vestibular, proprioceptive, and visual function, as well as cognition and musculoskeletal function. Elderly persons who fall in institutions are usually more physically and/or cognitively impaired, and therefore intrinsic factors contribute most to falls and fall-related injuries. ➢ What are extrinsic risk factors? o Extrinsic risk factors are related to environmental hazards and challenges such as poor lighting, stairs, clutter, and throw rugs. Extrinsic factors are implicated in up to 50% of all falls in the elderly in community settings. ➢ Among older adults living in the community, when and where do most falls occur? o Among the elderly living in the community, most falls occur during usual activities such as walking. Indoor falls occur most often in the bathroom, bedroom, and kitchen. o In institutions, the most common sites of falls are the bedside (during transfers into or out of bed) and the bathroom ➢ What can you do to prevent falls? o ASSESS. Most tools contain a fall history, an examination of mental and mobility status, a checklist for the presence of sensory deficits, a list of medications the client is receiving, and a list of primary and secondary diagnoses. o In the inpatient setting, orientation to the environment with an emphasis on safety devices is the first step in preventing falls. Other strategies include nonskid slippers or shoes, hip protectors, removal of obstacles and clutter, having the commode close to the bed, having the call light within easy access, and encouraging use of glasses and hearing aids. The avoidance of physical restraints, such as raised side rails, and maintaining the bed in the lowest position are essential in reducing the severity of falls. ➢ What are the types of restraints used? Physical (waist restraint, wrist restraint, geriatric chair) and chemical (benzo’s, anti-psych’s) ➢ What are the effects of restraint use on the elderly? Increases risk for falls, higher risk for problems associated with immobility such as pressure ulcers, contractures, and confusion. Many elderly experience feelings of anger, fear, humiliation, discomfort, demoralization, and punishment when they are restrained. ➢ What are alternatives techniques (instead of restraints) to deal with wandering, combative or confused patients? o Distraction, using a family member, moving a patient closer to the nurses station, magazines and newspaper, sitter, restraint alternatives (lap table that can be removed, etc.), bed alarms, soothing music/relaxation, regular attention to personal needs, removal of obstacles/safer physical design, use of personal assistive devices like hearing aids, glasses. ➢ Identify ways to promote healthy living among the elderly o • Maintain a healthy weight and diet. o • Stay active. o • Practice fall prevention. o • Make connections—maintain relationships with others. o • See medical personnel regularly—physician, eye doctor, dentist ➢ What are the two most widely publicized components of health promotion? o Exercise and nutrition ➢ What are some of the preventive care services covered under Medicare? o Annually, those with prediabetes every 6 months; no deductible or copayment. o Not covered routinely, but includes most people age 65+ (if overweight, family history, fasting glucose of 100–125 mg/dl [prediabetes], hypertension, dyslipidemia). ➢ Mammogram o Covered annually; no deductible, copayment applies ➢ Prostate cancer o Covered annually; no deductible or copayment. o Digital rectal examination and PSA test. ➢ Smoking Cessation o Two quit attempts annually, each consisting of up to four counseling sessions. o Limited to those with tobacco-related diseases (heart disease, cancer, stroke) or drug regimens that are adversely affected by smoking (insulin, hypertension, seizure, blood clots, depression). Clinicians are encouraged to become credentialed in smoking cessation. ➢ Immunization o No deductible or copayment. o Influenza vaccination covered annually; pneumococcal vaccination covered one time, revaccination after 5 years dependent on risk. ➢ Describe a health contract. o The client is helped to choose an appropriate behavior change goal and to create and implement a plan to accomplish that goal. The statement of the goal and the plan of action are then written into a contract format. • Identifies and enhances motivation • Clarifies measurable and modest goals • Suggests tips to remember new behaviors • Provides a planned way to involve support persons such as family and friends ➢ Explain Bailey's Bull's eyes o The goal of the bull’s-eye is for people to consume the nutritious foods that are listed in the center of it. These foods are low in saturated fat, sugar, and sodium, and high in fiber. ➢ Discuss Healthy People 2010 and 2000. o Healthy People 2010 is an initiative of the U.S. Department of Health and Human Services that utilized the skills and knowledge of an alliance of more than 350 national organizations and 250 state public health, mental health, substance abuse, and environmental agencies to develop a set of health care objectives designed to increase the quality and quantity of years of healthy life of Americans and to eliminate health disparitie ➢ Define health promotion vs. health screening. o Health promotion activities are those activities in which an individual is able to proactively engage in order to advance or improve his or her health o Health screening is a form of secondary prevention and will be a focus of this chapter. In order to endorse screening for a specific disease, the USPSTF considers whether the disease occurs with enough frequency in a population to justify mass screening. ➢ What are the three types of prevention and provide an explanation and example of each. o Primary prevention activities are those designed to completely prevent a disease from occurring, such as immunization against pneumonia or influenza. o Secondary prevention efforts are directed toward early detection and management of disease, such as the use of colonoscopy to detect small, cancerous polyps or a mammogram. o Tertiary prevention efforts are used to manage clinical diseases in order to prevent them from progressing or to avoid complications of the disease, as is done when beta blockers are used to help remodel the heart in congestive heart failure ➢ What is the chronic disease self-management program (CDSMP)? o is a 17-hour course for patients with chronic diseases that is taught by trained laypeople. The course goal is to teach patients to improve symptom management, maintain functional ability, and adhere to their medication regimens. The proven effectiveness of the intervention is, at least in part, attributable to the improved self-efficacy of clients who participate in the program. Clients come to believe that they can succeed in managing their illness and preventing disability. ➢ What are the barriers to physical activity for the older adult? o Barriers to physical exercise that have been identified by the elderly include lack of access to safe areas to exercise, pain, fatigue, and impairment in sensory function and mobility ➢ What is the risk for a sedentary life style? ➢ What are the four leading causes of death in the US? o cancer, diabetes, coronary heart disease, and cerebral vascular accidents ➢ Are older adults at risk for poor nutrition? If so, why? Explain the barriers for older adults in regards to good nutrition? o Elderly clients may be at increased risk for poor nutrition due to the fact that they have multiple chronic illnesses, may have tooth or mouth problems that may interfere with their ability to eat, may be socially isolated, may have economic hardship, may be taking multiple medications that can cause changes in appetite or gastrointestinal symptoms, and may need assistance with self-care. ➢ What is a healthy weight or BMI and when should we be concerned? o The Nutrition Screening Initiative suggests that a BMI of 22–27 is considered normal. Values above or below this range suggest over- and underweight, respectively. ➢ What are the lab values that could show malnutrition in the older adult? o Serum albumin: Less than 3.5 g/dl is associated with malnutrition and increased morbidity and mortality. ➢ Explain the general guidelines to dietary counseling. o Limit alcohol to one drink a day for women, two daily for men. o • Limit fat and cholesterol. o • Maintain a balanced caloric intake. o • Ensure adequate daily calcium, especially for women. o • Older adults should consume vitamin B12 in crystalline form, which can be derived from fortified cereals and supplements. o • Older adults who have minimal exposure to sunlight or who have dark skin need supplemental vitamin D. Daily vitamin D intake should be 400–600 IU and can be derived from fortified foods or supplements. o • Include adequate whole grains, fruits, and vegetables. o • Drink adequate water. ➢ What are the environmental risk factors that can be dangerous for an older adult? Can you explain ways to modify the environment to address these safety issues? o Environmental conditions that contribute to falls are slippery surfaces, stairs, irregular surfaces, poor lighting, incorrect footwear, and obstacles in the pathway. ➢ Some of the risk factors are client related. What changes of aging can make the patient at risk? o Elderly adults are susceptible to falls as a result of changes of aging like: postural instability, decreased muscle strength, gait disturbances and decreased proprioception, visual and/or cognitive impairment, and polypharmacy. ➢ Are older adults at risk for alcohol abuse? If they are, what can be done to re- educate them and prevent harm? o The USPSTF found good evidence that screening is beneficial in identifying patients whose alcohol consumption patterns place them at risk for increased morbidity and mortality, and good evidence that counseling about alcohol reduction can produce sustained benefit over a 6- to 12-month period. Screening Recommendations: • Blood pressure: Begin early adulthood, annually, ending around age 80. • Cholesterol: Begin early adulthood, every 2–3 years, ending around age 80. • Colorectal cancer: Begin age 50, every 5–10 years for colonoscopy, ending around age 80. • Mammogram: Begin age 40, every year or two; begin age 50 annually; begin age 65 every 2 years; ending around age 80. • Osteoporosis: Begin early adulthood for women (no frequency recommended); every 2– 3 years after age 65 for women, less frequently for men. • Pap test: Begin with female sexual activity, two normal consecutive annual screenings, followed by every 3 years; two normal consecutive annual screenings around age 65, then discontinue. • Prostate cancer: Do not do routinely, except if there is a family history or African American heritage. #6 Competency 742.1.6: Technology-Assisted Care of Older Adults The graduate collaborates with patients, families and the inter-professional team to select the appropriate application of technology to enhance older adults' safety and independence. This topic addresses the following learning objectives: • Recognize the value of electronic health records to care coordination among older adults across various health care settings and providers. • Identify the major types of assistive technology commonly used to enhance older adults’ function, independence, and safety. • Explain the teaching methods for introducing an older adult patient to a new technology. • Select appropriate communication technology to promote optimal transitions of care for older adults. • Select cost-effective assistive technology to promote quality of life for older adults. • Select strategies for collaborating with older adults, families, and caregivers on applying technology to enhance function, independence, and safety. • Recommend steps to successfully introduce a new technology to an older adult in a given situation. • Evaluate an older adult’s response to a newly introduced assistive technology. Assistive technology is designed to fill the patient’s gap in functional ability. This goes back to the ADLs and IADLs. What can they do and what can they not do. Can we put something in place to help them? • Assistive technology encompasses a broad range of devices from “low tech” (e.g., pencil grips, splints, paper stabilizers) to “high tech” (e.g., computers, voice synthesizers, Braille readers). These devices include the entire range of supportive tools and equipment, from adapted spoons to wheelchairs and computer systems for environment control. 1 Chapter 16 is the technology chapter. There is a loss of strength, balance, visual and auditory, cognitive, and/or memory changes that occur as we age. Assistive technology is designed to help us with these losses & bridge the gap between capabilities and care needs. 1 It is anything that can enhance the function of some physical or mental ability that is impaired. It can be a cane, walker, glassed, hearing aids, wheelchair, bath bench, elevated toilet seat. All of this is assistive technology. It is filling the functional gap. 1 How do you teach an older adult about the assistive technology? Chapter 9- How older adults learn. Focus on the practical application and benefits of using them. Which type of patients are more likely to use assistive devices? 2 Review Box 16-1 on page 564: Guidelines for Introducing Technology & Teaching the Elderly about its Use: • The use of technology must be perceived as needed and meaningful, and must be linked to the lifestyle of the person. • Cautions and disbelief in one’s capability may be an obstacle in accepting new technology and must be considered when creating the learning environment. • A generous amount of time as well as repeated short training sessions should be allowed. • More stress should be placed on the practical application of the device than on its technical features. • Only selective, central facts should be presented. • Mnemonics and cues will favorably affect self-efficacy in handling new products. • Training sessions should be held in the home or natural meeting places of the elderly. • The instructor should be well known by the elderly or introduced well in advance of the training. • The attitudes of the instructors toward the aged must be positive and realistic. 3 Briefly discuss assistive robots and sensor-based monitoring systems that we may see used in the future and why they may be useful 1. Nursebot- The robot provides a research platform on which to test out a range of ideas for assisting these adults, such as: • Intelligent reminding: Many older adults have to give up independent living because of memory loss. They forget to visit the restroom, to take medicine, to drink, or to see the doctor. One project explores the effectiveness of a robotic reminder, which follows people around, so they cannot become lost. • Tele-presence: Professional caregivers can use the robot to establish a “tele- presence” and interact directly with remote care recipients. This makes many doctor visits unnecessary. • Data collection and surveillance: Robots can be used for a wide range of emergency conditions that can be avoided with systematic data collection (e.g., certain types of heart failures). • Mobile manipulation: A semi-intelligent mobile manipulator integrates robotic strength with a person’s senses and intellect. This mobile manipulation can overcome barriers in handling objects (e.g., refrigerator, laundry, and microwave) that currently force older adults to move into assisted-living facilities. This technology could be used for any person dealing with function problems, such as arthritis, as the main reason for giving up independent living. • Social interaction deprivation: This affects a huge number of elderly people who are forced to live alone. This project seeks to explore whether robots can take over certain social functions for these older adults 2. Sensor Based: The goal of this system is to enable older adults with disabilities to remain in their own homes for as long as possible. The system is composed of unobtrusive and low-cost sensors (no cameras or microphones) that detect movement and pressure. There is a data logging and communications module, in addition to an integrated data management system, linked to the Internet. Using the appropriate data analysis tools, important observations about activities of daily living can be made from the data generated by the monitored person. These observations may yield early indicators of the onset of a disease or a sudden change of activity (or inactivity) that can indicate an accident. #7 Competency 742.1.7: Health Care System and Health Policy The graduate evaluates the effectiveness of the healthcare environment and the influence of health policy in providing care that maximizes the function and independence of older adults in accordance with individual patient characteristics and patient and family needs. This topic addresses the following learning objectives: ➢ Explain the implications of an aging population for health policy. ➢ Compare the foundational principles, goals, and methods of identified government programs and other community health initiatives available to older adults. ➢ Identify community resources for older adults that facilitate autonomy and quality of life for a given scenario. ➢ Compare the opportunities and constraints of supportive living arrangements on the function and independence of older adults. ➢ Analyze healthcare trends related to the independence and autonomy of older adults. ➢ Analyze a given policy or legislative act that promotes or hinders the independence and autonomy of older adults. ➢ Compare the benefits and limitations of the major forms of reimbursement on the delivery of healthcare services to older adults, differentiating the roles of Medicare and Medicaid. ➢ Explain the elements of the triple aim of healthcare reform as reflected in the care of older adults. ➢ Evaluate the influence of payer systems on access, quality, and affordability of healthcare for older adults. ➢ The Patient Protection and Affordable Care Act was signed into law in 2010. The intention: 1 Eliminate lifetime limits for health insurance coverage for essential services 1 Eliminate the ability of insurance companies to rescind coverage 1 Free Preventative care 1 Development of a prevention and public health fund. 1 Increase access to affordable care, including a provision for preexisting 1 Quality improvement and risk reduction ➢ The Independence at Home Demonstration: NP’s worked with patients to help them experience a higher level of independence through better management of their chronic illnesses ➢ Provisions that have already taken effect: 1 Improved drug discounts for Medicare recipients 1 Coverage for young adults through parental health insurance until age 26. 1 Expanding coverage for early retirees 1 National preexisting-condition insurance plan to assist those individuals without coverage for at least 6 months due to a prior condition. 1 2012 mandate The US Supreme Court upheld provisions to expand Medicaid and Medicare coverage a The Medicare expansion program requires participating states to expand coverage to most individuals under the age of 65 with income below poverty levels outlined in the Act. 1 The intent of PPACA in terms of Medicare is to reduce overall cost while maintaining coverage to those entitled to Medicare. 1 A national Medicare pilot program will be developed to provide Medicare recipients with more options for long-term care, including primary care services in their homes rather than institutional care. 1 Increase services that will impact the older population include providing wellness and prevention programs at no cost to the individual and prescription drug discounts. ➢ Need to know what Part A and Part B of Medicare covers o Medicare Part A helps to cover inpatient hospital care, inpatient care in a skilled nursing facility (for transitional, but not custodial care), hospice care, and home health care services. Financed by payroll taxes paid by the employer and employee, Medicare Part A is available without charge for those who are eligible to receive Social Security or Railroad Retirement benefits. If an individual is 65 years of age and has not worked 10 years (40 quarters) in a job that has paid Medicare taxes, he or she can still receive Medicare Part A by paying a premium. o Part B, previously referred to as Supplemental Medical Insurance (SMI), is considered medical insurance. It covers some of the cost for laboratory services, home health care services, doctor services, some outpatient therapies, mental health services, and outpatient hospital services. Participation in Medicare Part B is not mandatory and is not funded by the Medicare trust fund. Participants may pay for Part B out of their Social Security checks. In 2008, premiums for Medicare Part B were based on income; for example, if an individual reported yearly income of $82,000 or below ($164,000 for a joint return) on his or her income tax return, the monthly premium was $96.40. o In addition to the Traditional Medicare Plan with Parts A and B, Medicare also offers a plan called Medicare Advantage, also referred to as Medicare Part C. This option offers managed care plans like health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Medicare Advantage plans provide all of the benefits of the hospital and medical insurance plans under original Medicare, but can charge different copayments and deductibles. o With the passing of the Medicare Prescription Drug Improvement and Modernization Act of 2003, Medicare Part D was added. This is the Medicare prescription option, and it offers multiple plans from which the beneficiary can choose ➢ What is Medicaid---what does it cover and who is eligible? o Medicaid is Title XIX of the Social Security Act. It is an assistance program that is jointly financed by the state and federal governments, but is administered by the state; therefore, coverage and eligibility differ from state to state. To qualify for Medicaid, an individual must fit into a category of eligibility and meet certain financial and resource standards. Medicaid provides three types of health protection: ▪ 1) health insurance for low-income families and people with disabilities ▪ 2) long-term care (LTC) for older Americans and persons with disabilities ▪ 3) supplemental coverage for low-income Medicare beneficiaries for services not covered by Medicare (e.g., eyeglasses, hearing aids, prescription drugs) as well as Medicare Part B premiums and Medicare Parts A and B deductibles and copayments. ➢ What is Triple Aim of healthcare reform? o Improving the patient experience of care (including quality and satisfaction) o Improving the health of populations o Reducing the per capita cost of health care #8 Competency: Care Transition The graduate determines the needs of older adults and their families & caregivers in coordinating patient-centered, safe transitions of care that aim to assure the least restrictive environment relative to strengths and vulnerabilities, and reduce unnecessary hospitalizations. This topic addresses the following learning objectives: ➢ Review each of the transitions models provided in the COS. What do they attempt to accomplish? o People who use the CTI model are : ✓ Significantly less likely to be readmitted to a hospital. ✓ Less likely to incur further high cost utilization ✓ More likely to achieve self-identified personal goals around symptom management and functional recovery. ➢ What are the problems associated with patient transfers ➢ What is the importance of discharge med reconciliation? ➢ What can be done to eliminate the problems? ➢ Cover the interdisciplinary team. Who is usually on the team? Who is most likely not going to be at a meeting? What is the team’s purpose and what is the role of the Nurse? #9 Competency 742.1.9: Palliative and End-of-life Care The graduate collaborates with patients and families to support palliative care needs in order to reduce symptom burden and treatment fatigue and enhance quality of life, as well as end-of-life care that is compassionate, respectful, patient centered, and family supported. This topic addresses the following learning objectives: • Identify fundamentals of pain and symptom management in the palliative care of patients with chronic illness. • Determine the needs and wishes of patients and families related to palliative care. • Recognize aspects of care, including pain and symptom management, as priorities that contribute to a dignified end-of-life experience. • Identify legal and ethical standards related to end-of-life care. • Describe effects of grief and mourning on older adults and their families. • Determine the needs and wishes of patients nearing the end of life. • Assess the availability of services and resources to provide comprehensive end-of-life care. • Recommend appropriate interventions to facilitate the wishes of the dying and their families. ➢ You must be able to explain the differences between curative, palliative, and end of life or hospice care. o Curative: life-prolonging, and acute care options focus on cure. Despite the findings of the SUPPORT study, there are those patients, families, and cultures who choose the life-prolonging focus of care of a hospital death. Many of these deaths will take place in an ICU setting, with tubes, vents, and devices to promote doing everything possible to preserve life. It is important that judgments not be made about these choices, but to note that other choices exist as well. o Palliative: Palliative care refers to the comprehensive management of the physical, psychological, social, spiritual, and existential needs of patients. It is especially suited to the care of people with incurable, progressive illnesses. The goal of palliative care is to achieve the best possible quality of life for patients and their families. Control of pain, of other symptoms, and of psychological, social, and spiritual problems is paramount. ➢ Make sure you understand what advance directives and living wills are as well as DNR and AND request. o There are several nationally recognized advance directives to help an individual identify their personal wishes in a legal manner and to share that information with the people around them, including medical personnel. Durable power of attorney, living will declaration, appointment of health care representative, do not resuscitate (DNR), and life-prolonging procedures declaration are all legally recognized documents for indicating one’s health care wishes o An AND order is considered a more descriptive and positive order than a DNR. Its focus is on allowing death as nature takes its course at the end of an illness. DNR implies taking something away, or not doing something for the patient (i.e., resuscitation), and can be viewed as a harsh and insensitive statement of medical care that promotes a feeling of abandonment by patients and families alike. AND provides for comfort measures so that even with the withdrawal of artificially supplied nutrition and hydration, the dying process would occur as comfortably as possible ➢ What is the nurse’s role in this? What are the steps to initiating and caring out the patients request especially when family disagrees/ ➢ What are the signs of impending death? o Fish out of water breathing o Unable to awaken ➢ What are they 2 main categories of pain? Nociceptive pain and Neuropathic pain. What types of medications works best with these types? o Neuropathic: Anticonvulants and Antidepressants ➢ Should an older adult in pain and receiving palliative care be concerned with addiction? NO. ➢ Recognize aspects of care, including pain and symptom management as priorities that contribute to a dignified end-of-life experience. How is quality of life influenced by burden of symptoms? ➢ Identify legal and ethical standards related to end-of-life care. ➢ Describe effects of grief and mourning on older adults and their families. ➢ Determine the needs and wishes of patients nearing the end of life. ➢ Assess the availability of services and resources to provide comprehensive end-of-life care. ➢ Recommend appropriate interventions to facilitate the wishes of the dying and their families. ➢ What are “5 Wishes”? o • The person chosen to make decisions when the individual can no longer make them for himself or herself—a durable power of attorney for health care o • The kind of treatment the person wants or doesn’t want—a living will o • How comfortable the person wants to be o • How the person wants to be treated by others o • What the person wants his or her loved ones to know [Show More]

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