3403: FINAL EXAM OLD CONTENT

Intimacy

"A warm, meaningful feeling of joy" Five relational components: -Commitment -Affective intimacy -Cognitive intimacy -Physical intimacy -Interdependence

Chronic Illness

"Chronic health problems are not fixable with shiny new technology, and do not promise the suspense, exhilarating hope, and dramatic ending that acute medical crises often do. They simply continue day after day, [they are] often invisible or misunderstood". Chronic illnesses are those that occur slowly and progress slowly. They have an irreversible presence and may be hidden to outsiders. The presence of a chronic illness may be as little as an inconvenience or as great as an impairment of one's ability to perform even the most basic self-care activities. In 2013, 30% of community-resident Medicare beneficiaries ages 65 and older reported difficulty in performing one or more activities of daily living (ADLs), and an additional 12% reported difficulty with one or more instrumental activities of daily living. By contrast, 95% of Medicare beneficiaries living in nursing facilities had difficulties with one or more ADLs, and 81% of them had difficulty with three or more ADLs. According to the U.S. Census Bureau's American Community Survey, some type of disability was reported by 36% of people age 65 and older in 2014. -Continues day after day -Occur and progress slowly -Level of impairment varies greatly - 2 of every 3 older Americans have multiple chronic conditions -Consequences? physical suffering, loss, worry, grief, depression, impairment in function, increased dependence

Myth 2: You'll Become Frail

-1/3 of people 65+ fall every year -Due in part to decrease in blood flow to the cerebellum (balancing center of brain) and inner ear and vision changes -Check your balance and strength -Be careful with blood pressure meds as they sometimes lower bp too much, causing dizziness when you stand and increasing risk of falls

Why is oral health important?

-A basic need -Age-related changes in the oral cavity, medical conditions, poor dental hygiene, and lack of dental care -Poor oral health is a risk factor for dehydration, malnutrition, and a number of systemic diseases -Pain from infected teeth, ill-fitting dentures, or oral candidiasis can limit eating ability and compromise comfort and quality of life

Spirituality

-A broader concept than religion -Encompasses a person's values or beliefs; search for meaning; and relationships with a higher power, with nature, and with other people -As people age and move closer to death, spirituality may become more important -Spiritual belief and practices play a central role in helping older adults cope with life challenges and are a strength in the lives of older adults

Retirement

-A developmental stage that may occupy 30 or more years of one's life -Stress associated with role changes -Growing concern for economic support for retirees -44% of retirees work for pay at some point after retirement (some for economic need and some for involvement) -Role changes - effect everyone in the family, involved different expectations (housework, child care for family members, social, identity crisis)

Falls and medications

-A number of medications are implicated in increasing fall risk (polypharmacy) -Review all medications, including over-the-counter and herbal medications and limited to those that are essential -Provide patient teaching related to fall risk, appropriate dosing, and drug-drug and drug-alcohol interactions -Drowsiness, confusion, imbalance in body, bladder control issues

TeamSTEPPS has a three-phased process aimed at creating and sustaining a culture of safety with:

-A pretraining assessment for site readiness. -Training for onsite trainers and health care staff. -Implementation and sustainment.

Reasons for lack of oral care

-Access -Varies by Socioeconomic Status -Transportation -NO Medicare coverage for oral health Access to dental care for older people may be limited and cost prohibitive -Those with the poorest oral health are economically disadvantaged, lack insurance, disabled, homebound, or institutionalized -If a seriously ill or institutionalized individual needs dental care, it can be challenging to have him or her transferred to a dental office -Medicare does not provide any coverage for oral health care services; Medicaid coverage varies

roles of involvement in health-related decision-making as

-Active. -Passive. -Collaborative. -Avoiding information.

Non-pharmacological therapy of AD

-Alterations in external environment - calm, organized and simplified, temp control -Alterations in personal environment - pain, discomfort dealt with -Alternations in attitude of caregiver - calm, non-confrontational, treat as equal -Exercise -Aromatherapy -Ginkgo biloba—memory aid -Hand massage if appropriate (some people with AD react strongly to touch)

Spiritual Distress

-An individual's perception of hurt associated with the part of his or her person that seeks to transcend the realm of the material -May be manifested by anger, guilt, blame, hatred, expressions of alienation, turning away from family and friends, inability to derive pleasure, and inability to participate in religious activities

Pharmacologic Treatments

-Analgesics (nonopioid and opioid agents) and adjuvant medications (antidepressants, anticonvulsants, and herbal preparations) -Need to consider age-related changes and conditions, -Medications started at the lowest dose possible and titrated up -Around-the-clock dosing best for chronic pain

Medications and Depression

-Antihypertensives -Angiotensin-converting enzyme (ACE) inhibitors -Methyldopa -Reserpine -Guanethidine -Antiarrhythmics -Anticholesteremics -Antibiotics -Analgesics -Corticosteroids -Digoxin -L-Dopa

Non-pharmacologic treatment of parkinsons

-Aromatherapy -Relaxation (tremors get worse with anxiety/stress) -Surgical management (relieve symptoms - not done often bc of side effects) -Deep brain stimulation (brain pacemaker) -Pallidotomy and Thalamotomy (improve balance - done even less often) -deep brain stim, pallidotomy and thalamotomy done when meds haven't been working

Elimination Implications for Gerontological Nursing and Healthy Aging

-Assessment •Obtain a complete history of UI; investigate stool incontinence, surgical and obstetric history, and medications •Use of laxatives and enemas •Digital examination is performed to determine the presence of a mass •Effect on quality of life

Assessment of Oral Health

-Assessment of the mouth, teeth, and oral cavity can identify oral health problems and serve as an early warning for some diseases -The MDS 3.0 requires information obtained from an oral assessment -Federal regulations mandate an annual examination for residents of long-term care facilities

Signs of Sexual Abuse

-Bruises or scratches in the genital or breast area -Fear or an unusual amount of anxiety related to either routine or necessary exam of the anogenital area -Torn undergarments or presence of blood

Assistive devices

-Can also improve functional ability and independence -Education is essential because improper use of these devices can lead to an increased fall risk

chronic pain

-Can develop slowly or after acute -Includes pain of 75% of individuals -Goal? Reduction for quality of life -Examples include postoperative, procedural, or posttraumatic

Capacity

-Can the person understand a problem and decision? (risks/benefits, options, and consequences) -How do they do with performing tasks? -Who can declare a person "incapacitated"? ONLY THE COURTS

Medical Conditions and Depression

-Cancers -Cardiovascular disorders -Endocrine disorders, such as thyroid problems and diabetes -Metabolic and nutritional disorders, such as vitamin B12 deficiency, malnutrition, diabetes -Neurological disorders, such as Alzheimer's disease, stroke, and Parkinson's disease -Viral infections, such as herpes zoster and hepatitis -Vision and hearing impairment

How can nurses help with decision making?

-Care transitions: safe to go home or not? -POLST: decision on CPR or not? -Listening to rounds -Family care

Signs of Psychological Abuse

-Caregiver does all of the talking in a situation, even though the elder is capable -Caregiver appears angry, frustrated, or indifferent while the elder appears hesitant or frightened -Caregiver or the care recipient aggressive toward one another or the nurse

Nurse's Roles in Care in Chronic Illness

-Counselor: listen to patient story and family experience, understand what gives that person meaning, help them set realistic goals; focus on potential and not limitations -Educator: teach about the illness, it's management and skills required for self-care -Nursing Practice: focus on prevention of complications (tertiary prevention), use evidence-based care -Coordinator: refer to other disciplines when needed, assess resources and refer to palliative care when appropriate

Factors Influencing Identification of Abuse of Older Adults

-Cultural or societal tolerance of violence, especially against women -Shame and embarrassment -Fear of retaliation -Fear of institutionalization -Social isolation -Unacceptability of emotional expression, especially that of fear or distress

Enhancing Communication with AD

-Depends on the cause, type, and severity of the symptoms -Collaborate with speech and language pathologist -Includes pictures, writing things down, being patient, working with families, music (comfort)

Diagnosing Delirium

-Disturbed attention/awareness -Change from baseline -Short time frame -One additional cognitive disturbance -Has a direct physiological cause

Aging Changes: Ears

-Ear loves sag, elongate and wrinkle -Course hairs in ears -Hearing loss often occurs (especially high frequency sounds) -Ear wax changes (bigger changes in men)

Myth 3: You Will Have No Interest in Sex

-For women, estrogen and testosterone levels decline by menopause, which can lower the sex drive and make sex physically uncomfortable. -Many older men still have a strong sex drive but might have erection problem because of low blood flow to the penis as a result of clogged arteries stemming from such conditions as high cholesterol and blood pressure levels.

Falls Implications for nursing

-Gerontological nurses need to be knowledgeable about fall risk factors and fall risk reduction -Health promotion interventions can help maintain fitness and mobility in older adults -Knowledge of the home environment and risk factors for falls is a must

Nursing home settings and falls

-Inadequate staff communication and training -Incomplete patient assessments -Environmental issues -Incomplete care planning -Inadequate organizational culture of safety

basic characteristics of a capacity examination

-It must be regarded as a "snapshot" of a patient's mental status and decision-making ability at a particular point in time -t it is not a global assessment of the patient's mental status and ability to make a multitude of decisions -can require consideration of multiple factors

Factors affecting fulfillment of healthy eating

-Lifelong eating habits -Acute and chronic illness -Medication regimens -Ethnicity and culture -Ability to obtain and prepare food -Mood -Socialization -Socioeconomic deprivation -Transportation and housing -Food knowledge

Beers Criteria

-List of potentially inappropriate medications for older adults (PIM's): Box 9.6 -Regulation for long-term care facilities as part of the Centers for Medicare and Medicaid Services -Meds on this list: must demonstrate benefits WAY OUTWEIGH the risks for use

Prevention of Elder Mistreatment

-Make professionals aware of potentially abusive situations. -Help families develop and nurture informal support systems. -Link families with support groups. -Teach families stress management techniques. -Arrange comprehensive care resources. -Provide counseling for troubled families.

Rockwood article: creativity and spirituality

-Music -Art -Dance -Journaling

Nurses may work with people in different phases of retirement

-Participate in retirement education and counseling programs -Provide anticipatory guidance about transition to retirement -Identify those who may be at risk for lowered income and health concerns -Refer to appropriate resources -Advocate for policies and conditions that allow older people to maintain quality of life in retirement

Goals of pain interventions

-Promote comfort -Maintain the highest level of functioning and self-care possible -Balance the risks and benefits of the various treatment options

Restorative Care: Home Health Care

-Provision of medically related services and equipment to patients and families in their homes for health maintenance, education, illness prevention, diagnosis and treatment of disease, palliation, and rehabilitation. -Involves coordination of services. -Coordinator of services—depends upon services provided -Focuses on patient and family independence. •Nursing is one service most patients use in home care. However, home care also includes medical and social services; physical, occupational, speech, and respiratory therapy; and nutritional therapy. •Most important: nurses need to be aware of other areas that directly affect home health care.

Sleep and Aging

-Sleep complaints are linked to other health problems or disorders -REM sleep changes as we age

Myth 1: You'll Sleep Poorly

-Sleep patterns do change as we age -Takes longer to fall asleep and tend to have more frequent awakenings -Less delta sleep (deeper stage that helps you consolidate memory) -Many sleep problems for older adults stem from other causes such as meds -Consider cognitive behavioral therapy for issues to help practice good sleep habits -Avoid sleeping pills

Parkinson's Disease

-Slowly progressing movement disorder -Slightly more common in men than in women -Exact cause is unknown (pesticides, virus, head trauma, genetic?) smoking is protective for parkinsons

Four generational subgroups

-Super-centenarians: ages 110+ -Centenarians: ages 100-109 -Those in-between: ages 79-99 -Baby boomers: ages 57-78

Acute pain

-Temporary -Universal experience -Often on top of other pain

The most common elements of the mental status examination include:

-Testing the patient's orientation to person, place, and time. -Conducting a serial seven test, where the examiner asks the patient to start with the number 100 and count backward by sevens. -Asking the patient to repeat and then a short time later recall three common, unrelated items. -Asking the patient to follow directions.

Urinary incontinence (UI)

-The involuntary loss of urine sufficient to be a problem -Is an underdiagnosed, underreported, and undertreated condition, especially in older adults -Treatment is not sought because of embarrassment, normal aging, or the older adult is uneducated about treatment -Stigmatized (shame) - 1/8 who have bladder control issues have been diagnosed -Geriatric syndrome

Importance of nutrition in the older adult

-The key element is preserving health -The quality and quantity of a diet will help prevent, delay the onset of, and manage chronic disease processes -Fulfillment of nutritional needs in aging is often affected by numerous factors -87% of older adults have diabetes, hypertension or high cholesterol

HIV/Aids and older adults

-The number of older people infected with the virus is growing ◦An older person's compromised immune system makes him or her more susceptible to HIV or AIDS ◦Normal changes in women increase the chance of infection

Pharmacologic Management of AD

-There is no cure -Pharmacologic therapy has the potential to slow cognitive decline in some •Cholinesterase inhibitors •N-methyl D-aspartate (NMDA) antagonist •Effectiveness of medications and side effects varies -Treat coexisting depression and other mental health issues

Risk Factors for UI

-Thought to be related to •Cognitive impairment •Limitations in daily activities •Institutionalization -Stroke, diabetes, obesity, poor general health, certain medications, and comorbidities are associated with urinary incontinence (UI) -public health problem: chronic but preventable -peaks during menopause

Types of Families

-Traditional couples -Divorced couples -Nontraditional couples, LGBT couples -Elders and their adult children -Never married older adults -Grandparents as custodial care providers of grandchildren -Siblings -Fictive kin; non-blood kin who become surrogate family such as friends, neighbors

UI is classified as....

-Transient (acute) OR -Established (chronic)

Family Compisition

-We are experiencing changes in family composition compared with previous generations -Multigenerational families (1800's- to mid-1900's) -Nuclear families (1950's on) -Now -Growing number of multigenerational households -Family members form the nucleus of relationships for most older adults and their support system if they become dependent -As families change, roles or expectations of one another may change as well

Signs of Neglect by Self or Caregiver

-Weight loss -Uncharacteristically neglected grooming -Evidence of malnutrition and dehydration -Fecal/urine smell -Inappropriate clothing to the situation or weather -Insect infestation

Delirium

-acute confusional state/decline in cognitive function and attention -potentially reversible cognitive impairment -occurs suddenly and worsens at night. -develops over a short time (hrs to days) -often has a physiological cause. -Fluctuates over the course of the day -Symptoms include reduced ability to focus accompanied by delusional (paranoid) thoughts and hallucinations A new onset of delirium should trigger the nurse to assess for signs and symptoms of infections such as pneumonia and UTI. The presence of delirium is a medical emergency and requires prompt assessment and intervention.

Hypertension Health Disparity

-african americans are 40% more likely to have hypertension -10% less likely to have controlled blood pressure

Screening for STIs in Older Adults

-any adult that is sexually active should be tested -can ask about HIV risk factors -all adults should be tested at least once for HIV -older women with risk factors should be screened annually -gay men should be screened once a year

Psychological Impacts on Sexuality

-attitudes -feelings -past experiences

Dangers of Osteoporosis

-fractures -disability -death

Indications for a Capacity Examination

-most common is a patient's refusal to accept medical treatment -primary provider simply does not feel comfortable, confident, or competent making the assessment.

Purpose of sleep and rest

-most important but least understood part of health -sleep is a basic need

Aging Changes: Skin

-skin is our largest organ -physical changes in the skin happen as a result of genetic and environmental factors -EPIDERMIS: thins and makes blood vessels and bruises more visible. fewer melanocytes leading to lighter appearance of skin. age spots and keratosis (thick brown raised lesions) appear -DERMIS: loses about 20% of thickness, blood vessels are reduced leading to paler skin, cooler overall skin temp, collagen synthesis decreases , elastin fibers thickened leading to loss of stretch and resilience (skin sag) HYPERDERMIS: atrophy happens, increased sensitivity to cold, inability to regulate temp.

4 Ways to Describe Aging

-social: role changes -functional: ability/loss of ability to do things -biological: changes in the body -chronological: numbers and birth dates

Why does polypharmacy happen?

-sometimes poor communication between different specialties -lines get crossed -people prescribe different things -increasing quality of life - sometimes too many meds are prescribed to try to do that

Danger Signs Related to Melanoma

-the deadliest form of skin cancer -teach people to look for the ABCDE of melanoma: asymmetry, border, color, diameter, evolving

Age related changes in spine if bone loss:

-what kyphosis looks like -hunch: loss of height

Seven ethnoracial groups in the United States

1. Black or African American 2. Asian American 3. Native Hawaiian or Pacific Islander 4. American Indian or Alaskan Native 5. White (of European descent) 6. Multiracial 7. Those who self-identify as Hispanic or Latino

A Simple Framework for Determination of Capacity

1. Is the patient able to communicate? 2. Has the proposed treatment or procedure been discussed with the patient by a qualified clinician? 3. Can the patient explain the treatment or procedure, the rationale for it, as well as the risks and benefits of having the treatment? 4. Can the patient explain the consequences of not having the treatment or procedure? 5. Can the patient explain in a coherent manner the rationale for his or her decision and demonstrate a reasonable appreciation of the factors involved?

Articles are usually set-up in a systematic way:

1. Problem identified 2. Previous work reviewed 3. Question addressed 4. How the study was conducted 5. Results and data analysis 6. Conclusion

Four Useful Strategies for Communicating With Individuals Experiencing Cognitive Impairment

1. Simplification Strategies (Useful With ADLs) 2. Facilitation Strategies (Useful in Encouraging Expression of Thoughts and Feelings) 3. Comprehension Strategies (Useful in Assisting With Understanding of Communication) 4. Supportive Strategies (Useful in Encouraging Continued Communication and Supporting Personhood)

Self-neglect

A behavior in which people fail to meet their own basic needs in the manner in which the average person would in similar circumstances -refuses or fails to take care of themselves

Sleep Apnea

A condition in which people stop breathing while sleeping Symptoms: -loud periodic snoring -gasping and choking upon wakening -unusual nighttime activities -morning headaches -poor memory -Irritability -personality changes Sleep apnea significantly increases inflammation in the body and has been shown to lead to cardiovascular disease.

Functional Assessment

A determination of functional status is part of the usual gerontological assessment. If the person is healthy and active, a simple statement may be all that is needed, such as "Patient is active and independent; denies functional difficulties." However, if any potential problems exist, such as for a person who has Parkinson's disease or for a person who recently fell, a more detailed assessment is conducted. A thorough functional assessment includes the following: • Identifying the specific areas in which help is needed • Identifying changes in abilities from one period of time to another • Assisting in the determination of the need for specific service(s) • Providing information that may be useful in determining the safety of the current living situation

Retirement

A developmental stage of life that may occupy 30 or more years of one's life -Characterized by transitions and role changes -Growing concern for economic support for retirees -44% of retirees work for pay at some point after retirement -Some because of economic need -Some work to remain involved and productive

Supplemental Security Income (SSI)

A federal program established to provide assistance to elderly persons and persons with disabilities Not all older persons living in the United States have Social Security benefits adequate to provide even the most basic necessities of life. This has been especially true for many of today's older adults. If they spent their lives employed in the agricultural industry, as domestic workers, or in the service industry and were paid very low wages, Social Security taxes were not withheld by their employers, or they were paid on a cash basis. SSI was established in 1965 to provide a minimum level of economic support to older adults and select others.

Medicare

A federal program of health insurance for persons 65 years of age and older

bone mineral density (BMD)

A measure of the amount of minerals (mainly calcium) contained in a certain volume of bone.

Restraints

A physical restraint is defined as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. A chemical restraint is when a drug or medication is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. Historically, restraints and side rails have been used for the "protection" of the patient and for the security of the patient and staff. Originally, restraints were used to control the behavior of individuals with mental illness considered to be dangerous to themselves or others

Power of Attorney (POA)

A power of attorney (POA) is a legal document in which one person designates another person (e.g., family member, friend) to act on his or her behalf. The two types are a general POA and a durable POA. The appointed person becomes known as the attorney-in-fact. The attorney-in-fact named in a general POA usually has rights such as to make financial decisions and pay bills in defined circumstances, but not necessarily to make decisions related to health care. The attorney-in-fact appointed in a durable POA usually has additional rights and responsibilities to make health-related decisions for persons when they are unable to do so themselves. This person is known as the health care surrogate or proxy.

Osteoporosis

A progressive metabolic bone disease with: ◦Loss of bone density ◦Structural deterioration of bone tissue MEANS: porous bone

Risk Factors

A risk factor is any attribute, quality, environmental situation, or trait that increases the vulnerability of an individual or group to an illness or accident -increase the vulnerability of an individual or a group to an illness or accident Risk factors include: -Genetic and physiological factors -Age -Environment -Lifestyle

Sexual Health

A state of physical, emotional, mental, and social well-being related to sexuality Influencing factors ◦Expectations ◦Activity levels ◦Cohort and cultural influences ◦Biological changes with age ◦Sexual dysfunction

Prevention of CAUTI: ABCDE

A: adherence to infection control B: bladder ultrasound could be used to aid in putting a catheter in C: condom catheter or other alternatives D: don't use them unless you have to E: early removal

Abuse vs. neglect

Abuse: ◦Intentional ◦May be physical, psychological, medical, financial, or sexual Neglect ◦Most often it is passive ◦Failure of action/care ◦It is active when care is withheld deliberately and for malicious reasons

Nonopioid analgesics

Acetaminophen -Used for the most common causes of physical pain -Should be considered a first-line approach Nonsteroidal anti-inflammatory drugs -Used when pain is from inflammation or during a short arthritic flare -Accompanied by higher risk for adverse drug effects

Activity Theory

Activity is possible when living in a stable society The older person has -Access to positive influences and significant others -Opportunities to participate in the broader society if he or she chooses to

Aphasia

Affects a person's ability to communicate with speech and his or her understanding of language, reading, writing, and gesturing Forms of aphasia include -Fluent aphasia: caused by damage to the Wernicke of the brain; person might speak easily but the content doesn't make sense -Nonfluent aphasia: damage to the broca area; speaking slowly and using minimal words and also issues with writing -Global aphasia: large lesion in left hemisphere; effects most or all of language; can't understand words or speak -Anomic aphasia: when individuals can understand and speak readily but have severe trouble finding words and can't name objects

Second victim syndrome

Affects healthcare providers when a medical error that results in significant harm to a patient and the patients family occurs. Often overlooked, nurses who have been involved in such a medical error can sustain complex psychological harm that can lead to detrimental outcomes such as suicide. These fatal errors can haunt nurses throughout their lives, leading to symptoms that are similar to post-traumatic stress disorder. One potential outcome is that nurses "move on" and work on gaining additional knowledge and skills to prevent errors in the future. But in many cases, nurses are reluctant to return to work because of fear of isolation from the organization, loss of confidence, remorse, depression, humiliation, and guilt. Being aware of the potential for second victim syndrome allows health care agencies to provide support the moment such an event occurs. Health care agencies need to provide support for as long as deemed necessary. Although the care and support of patients and families is a priority, the second victim has a right to be treated with respect and dignity and to be supported by peers and the organization. Proposed rights for second victims include respect, just treatment, understanding.

Assessment of Patient Understanding

After gaining information about the patient's medical and psychosocial issues, the time comes to assess the patient's understanding of his or her medical condition. -the clinician assesses the patient's ability to understand the risks and benefits of the treatment or procedure, as well as the consequences of accepting or refusing the intervention. -Assessing the patient's level of understanding regarding the consequences of refusing the clinician's advice is important. -the patient must be able to offer a logical, coherent reason for accepting or refusing the intervention.

Alarms/Motion Sensors

Alarms, either personal or chair/bed, are often used in fall prevention programs. There has been no research to support their effectiveness in prevention of a fall and "at best, it can shorten 'rescue time' ". Some have suggested that the use of these alarms may increase patient agitation, especially in cognitively impaired individuals, impede functional status, and negatively impact feelings of dignity among older adults in nursing homes. The use of alarms may be more for the needs of the staff rather than the patients. Silent alarms, visual or auditory monitoring systems, motion detectors, and physical staff presence may be more effective. A recent study reported that use of motion sensors inside patient

Pharmacological Approaches to Dementia

All evidence-based guidelines endorse an approach that begins with comprehensive assessment of the behavior and possible causes followed by the use of nonpharmacological interventions as a first line of treatment except in emergency situations when BPSDs could lead to imminent danger or compromise safety. Despite these recommendations, antipsychotic medications to treat BPSDs are often given as the first-line response in nursing homes, hospitals, and ambulatory care centers without appropriate determination of whether there is a medical, physical, functional, psychological, psychiatric, social, or environmental cause of the behaviors. Often, these drugs are prescribed in response to frustration and helplessness on the parts of both professionals and loved ones, in addition to inadequate knowledge of BPSDs in dementia and nonpharmacological interventions

Alcohol Use Disorder: Gender Issues

Although men (particularly older widowers) are four times more likely to abuse alcohol than women, the prevalence in women may be underestimated. The number and impact of older female drinkers are expected to increase over the next 20 years as the disparity between men's and women's drinking decreases. Women of all ages are significantly more vulnerable to the effects of alcohol misuse, including faster progression to dependence and earlier onset of adverse consequences. Even low-risk drinking levels (no more than one standard drink per day) can be hazardous for older women. Older women also experience unique barriers to detection of and treatment for alcohol problems. Health care providers often assume that older women do not drink problematically, so they do not screen for alcohol abuse. Often alcohol abuse in women is undetected until consequences are severe.

Considerations of Common Changes in Late Life During the Physical Assessment: Neurological

Although there is a gradual decrease in muscle strength, it still should remain equal bilaterally. Greatly diminished or absent ankle jerk (Achilles) tendon reflex is common and normal. Decreased or absent vibratory sense of the lower extremities is common, making testing unnecessary.

Anomic Aphasia

Anomic aphasia is associated with lesions of the dominant temporoparietal regions of the brain, although no single location has been identified. Persons with anomic aphasia understand and speak readily but may have severe word-finding difficulty. They may be unable to remember crucial content words. This is a frequent form of aphasia characterized by the inability to name objects. They struggle to provide the correct noun and often become frustrated at their inability to do so.

Pharmacological Approaches to Delirium

Antipsychotic drugs are routinely used to treat delirium even though the U.S. Food and Drug Administration has not approved their use for treating the condition. The American Geriatrics Society guidelines suggest avoiding use of these medications as a part of the routine care of individuals with delirium. A recent systematic review and meta-analysis evaluating the effectiveness of antipsychotics for the prevention or treatment of delirium concluded that current evidence does not support the use of these medications. Limited use of antipsychotics may be considered if the patient's life or safety is at risk because of severe agitation. Non-drug treatments, discussed previously, are first-line treatment for delirium

Insomnia and Alzheimer's Disease

Associated behaviors: -agitation, wandering, comorbid illnesses, primary sleep disorders Behavioral techniques: -sleep hygiene education, daily walking, and increased light exposure

Danger Signs: Remember ABCDE

Asymmetry of a mole (one that is not regularly round or oval) Border is irregular Color variation (areas of black, brown, tan, blue, red, white, or a combination) Diameter greater than the size of a pencil eraser (although early stages may be smaller) Elevation and Enlargement*

Bathing Someone with Dementia

Bathing Bathing is an essential aspect of everyday life that most people enjoy. However, bathing and care for ADLs can be perceived with fright as a personal attack by persons with dementia who may respond by screaming or striking out. In institutional settings, a rigid focus on tasks or institutional care routines, such as a shower three mornings each week, can contribute to the distress and precipitate distressing behaviors. The behaviors that may be exhibited are not deliberate attacks on caregivers by a violent person, but rather a way to express self in an uncertain situation. The message is, in the words of Rader and Barrick: "Please find another way to keep me clean, because the way you are doing it now is intolerable"

Sensory Impairments in Older Adults

Because of common sensory impairments experienced by older adults, you need to promote existing sensory function and be sure that patients live in safe environments. Whenever you provide care activities, make sure that patients wear assistive devices such as a hearing aid or glasses so that they can fully participate in care. Chapter 49 describes in detail the nursing interventions used to maintain and improve sensory function.

Considerations of Common Changes in Late Life During the Physical Assessment: Abdomen

Because of deposition of fat in the abdomen, auscultation of bowel sounds may be difficult.

Considerations of Common Changes in Late Life During the Physical Assessment: Neck

Because of loss of subcutaneous fat it may appear that carotid arteries are enlarged when they are not.

Nonpharmacological Approaches to Delirium

Because the etiology of delirium is multifactorial, interventions that are multicomponent and address more than one risk factor are more likely to be effective. Interprofessional approaches to prevention of delirium seem to show the most promising results, but continued research is needed to evaluate what type of approach has the most beneficial effect in specific clinical settings. A person-centered approach to care, rather than a disease-focused approach, can yield the best outcomes.

UI Nursing Interventions

Behavioral: •Scheduled voiding •Bladder training •Prompted voiding •Pelvic floor muscle exercises •Lifestyle modifications: increasing fluid intake, decrease weight, exercise -absorbent products -nonsurgical devices -pharmacologic treatment (choice depends on drug effects, drug-drug and drug-disease interactions, dosing frequency, titration range, and cost) -surgical treatment (colposuspension/burch operation, slings) -catheters (urinary, indwelling, external, intermittent catheterization) •indwelling not appropriate for long-term management

Bladder Training

Bladder training aims to increase the time interval between the urge to void and voiding. This method is appropriate for people with urge UI who are cognitively intact and independent in toileting or after removal of an indwelling catheter. Bladder training involves frequent voluntary voiding to keep bladder volume low and suppression of the urge to void using pelvic muscle contractions, distraction, or relaxation techniques. When the individual feels the urge to urinate, the person uses the urge control techniques. After the urge subsides, the person walks at a normal pace to the toilet. The initial toileting frequency is every 2 hours and it is progressively lengthened to 4 hours, depending on tolerance, over the course of days or weeks

Aging Changes: Neurological

CNS -Brain size and weight decreases causing a decrease in the number of neurons, dendrites can wear out and increased risk of trauma -Subtle changes in cognition and motor function in VERY old -Mild memory impairments -Balance changes -Length to perform tasks increases PNS -Reaction time is delayed -Decrease in tactile senses: fingertips, palms, lower extremities (touch and feel decreased) *Increased risk of injury from fire or falling

Cognitive Reserve (CR)

CR is based on the concept of neuroplasticity and refers to the strength and complexity of neuronal/dendrite connections from which information is transmitted and cognition/mentation emerges. The greater the strength and complexity of these connections, the more the brain can absorb damage before cognitive functioning is compromised. To maximize brain plasticity and CR, it is important to engage in challenging cognitive, sensory, and motor activities, as well as meaningful social interactions, on a regular basis throughout life.

Who can determine capacity?

Capacity is often confused with competency, which is a legal term and can only be determined by a court.

Progressively lowered stress threshold

Categorizes symptoms into four groups: cognitive loss, personality changes, planning losses that cause a decline in functional abilities, loss of a stress threshold -goal is to decrease all categories of stressors in the hopes it will increase positive outcomes -First model used to plan and care -Care decreases the stressors and provides a safe, predictable environment

The Biological Clock Theory

Cell reproduction and death of cells is genteically preprogrammed. This helps determine a person's life span.

Cellular Functioning Theory

Cells need to reproduce and if that reproduction was always the same nothing would change. Cells become more complex as we age, they can get disorganized and not change/duplicate themselves in the same way and ultimately cellular death occurs. Says that because of these changes in our cells we age and die

Considerations of Common Changes in Late Life During the Physical Assessment: Ears

Cerumen impactions are common. These must be removed before hearing can be adequately assessed or tympanic membrane visualized.

Pharmacological Approaches to Depression

Choice of medication depends on comorbidities, drug side effects, and the type of effect desired. People with agitated depression and sleep disturbances may benefit from medications with a more sedating effect, whereas those who are not eating may do better taking medications that have an appetite-stimulating effect. There are more than 20 antidepressants approved by the FDA for the treatment of depression in older adults. The most commonly prescribed antidepressants are the selective serotonin reuptake inhibitors (SSRIs). These agents work selectively on neurotransmitters in the brain to alleviate depression. The SSRIs are generally well tolerated in older people. Many are now available in both tablet and oral concentrate forms for easier use. Side effects are manageable and usually resolve over time; most cause initial problems with nausea, vomiting, dizziness, dry mouth, or sedation. Hyponatremia can also occur. If sexual dysfunction occurs, it will resolve only with discontinuation; therefore, if the person is or plans to become sexually active, a different drug may be necessary.

Decisional Congruence

Choices considered congruent by the decision-maker are those decisions that are consistent with the older adult and the family's view of themselves and are personalized within the context of their lives. Incongruence, or lack of agreement among the decision-maker and family or support individual and the health care team member, may set up decisional conflict. Decisional conflict is defined as the lack of agreement between the presented alternatives and the older adult's value system.

Adult Cognition

Cognition is the process of acquiring, storing, sharing, and using information. Components of cognitive function include language, thought, memory, executive function (planning, organizing, remembering, paying attention, solving problems), judgment, attention, and perception. The determination of intellectual capacity and performance has been the focus of a major portion of gerontological research. Emerging research suggests that cognitive function and intellectual capacity is a complex interplay of age-related changes in the brain and nervous system and many other factors such as education, environment, nutrition, life experiences, physical function, emotions, biomedical and physiological factors, and genetics

Cognitive Changes in Older Adults

Cognitive Changes A common misconception about aging is that cognitive impairments are widespread among older adults. Because of this misconception, older adults often fear that they are, or soon will be, cognitively impaired. Younger adults often assume that older adults will become confused and no longer able to handle their affairs. Forgetfulness as an expected consequence of aging is a myth and not a fact or expectation. Some structural and physiological changes within the brain are associated with cognitive impairment. Reduction in the number of brain cells, deposition of lipofuscin and amyloid in cells, and changes in neurotransmitter levels occur in older adults both with and without cognitive impairment. Symptoms of cognitive impairment such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require you to further assess patients for underlying causes. There are standard assessment forms for determining a patient's mental status, including the Mini-Mental State Exam-2 (MMSE-2), the Mini-Cog, and the Clock Drawing Test

Prevention of pressure ulcers

Comprehensive program including •Patient education •Training for all members of the health care team •Use of toolkits and protocols (prevention bundles) •Risk assessment •Skin assessment •Nutritional assessment •Repositioning •Appropriate support surfaces

Assessment for Depression

Contrary to myth, depression is not a normal part of aging, can delay recovery from a medical illness, and is treatable. The short-form (15-item) Geriatric Depression Scale (GDS) is a valid and reliable assessment instrument that can differentiate between depressed and nondepressed older adults. It takes approximately 5-7 minutes to administer and score but is not a substitute for a clinical interview, nor does it identify suicide risk. -Use an assessment tool -Ask about thoughts of self harm -Sleep/nutrition -Physical exam -Psychosocial assessment -Cognitive assessment -Functional assessment -Lab work/medications -Involve family

Nonpharmacological Approaches to Depression

Current evidence shows that both cognitive-behavioral therapy (CBT) and second-generation antidepressants have similar effectiveness but the medications are more likely to cause harm than the utilization of CBT alone. The American College of Physicians recommends that clinicians choose between either CBT or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient. Other types of nonpharmacological treatment that have been found to be helpful in depression include family and social support, education, grief management, exercise, humor, spirituality, CBT, brief psychodynamic therapy, interpersonal therapy, reminiscence, life review therapy, problem-solving therapy, and complementary therapy (e.g., tai chi). The development of effective, simplified, and accessible psychotherapeutic approaches, including telephone or Internet-based programs, is important.

Calcium Sources

Dairy products (e.g., yogurt, milk, cheese) Chinese cabbage or bok choy Tofu (calcium fortified) Soy milk (calcium fortified) Orange juice (calcium fortified) Dried figs Cheese pizza Green, leafy vegetables (e.g., broccoli, brussels sprouts, mustard greens) Beans/legumes Tortillas Cooked soybeans Sardines or salmon with edible bones Nuts (especially almonds) Bread

Treatment of Sleep Apnea

Depends on the type -Losing weight -Avoiding alcohol and sedatives -Stopping smoking -Avoiding supine sleeping -Wearing a continuous positive airway pressure (CPAP) device at bedtime

Consequences of Depression

Depression is a common and serious medical condition second only to heart disease in causing disability and harm to an individual's health and quality of life. Depression and depressive symptomatology are associated with negative consequences, such as delayed recovery from illness and surgery, excess use of health services, cognitive impairment, exacerbation of coexisting medical illnesses, malnutrition, decreased quality of life, and increased suicide and non-suicide-related deaths (Abbasi & Burke, 2014; Alexopoulos, 2014; Sacuiu et al., 2016). It is highly likely that nurses will encounter a large number of older people with depressive symptoms in all settings. Recognizing depression and enhancing access to appropriate mental health care are important nursing roles to improve outcomes for older people.

First Generation Theories

Early psychosocial theories of aging were an attempt to explain and predict the changes in middle and late life with an emphasis on adjustment. Adjustment was seen as an indication of success, at least by the academic theoreticians who developed them. The majority of these theories began appearing in the gerontological literature in the 1940s and 1950s. They were not based on extensive research. Early theories focused on adjustment as an indicator of success. They weren't really researched early on, but came from personal and professional experiences of clinicians. -Role Theory -Activity Theory **first generation theories criticized because hard to apply. Fail to consider social class, education, economic and cultural diversity. Good to know where we began!

Crisis Proof:

Effective, combines the ability for change with the need for stability; shown to have more support and family stability

Electrical Field

Electrical Field There are numerous fields influenced by electrically charged particles from molecules, cells, and organs of different frequencies that work together harmonically and present as complex waves. Many electrical elements of a living organism's energy fields have been carefully measured, including electrocardiography and electroencephalogram. In addition to these well-known tests, the electroencephalography field near skin, which has been found to decline with aging, is used to noninvasively assess wound healing.1 Electricity is also used for healing. Transcutaneous Electrical Nerve Stimulation (TENS) that has been used to effectively treat chronic pain for decades and to repair tissue such as bone fractures.2-4 Depression can be treated with electrically stimulating seizure activity.5 Electricity can also be dangerous, even beyond the electric shocks we have all experienced. There have been links made between the presence of high-voltage power lines and increased risk of childhood leukemia.6 We are electrical beings, influenced by waves of electricity.

Enemas

Enemas of any type should be reserved for situations in which other methods produce no response or when it is known that there is an impaction. Enemas should not be used on a regular basis. A normal saline or tap water enema (500 to 1000 mL) at a temperature of 105°F is the best choice. Sodium citrate enemas are another safe choice. Soapsuds and phosphate enemas irritate the rectal mucosa and should not be used. Oil retention enemas are used for refractory constipation and in the treatment of fecal impaction.

Generativity vs. Stagnation

Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service -looking at finding important work in middle age -actual work, helping others, caring for the future, leaving the world a better place -might look different for everybody Stagnant would be staying stagnant and not finding that for yourself

Considerations of Common Changes in Late Life During the Physical Assessment: Temperature

Even a low-grade fever could be an indication of a serious illness. Temperatures as low as 100° F may indicate pending sepsis.

Fallophobia

Even if a fall does not result in injury, falls contribute to a loss of confidence that leads to reduced physical activity, increased dependency, and social withdrawal. Fear of falling (fallophobia) may cause a person to restrict his or her physical and social activities, leading to further functional decline, depression, social isolation, and decreased quality of life. Fear of falling is an important predictor of general functional decline and a risk factor for future falls

Considerations of Common Changes in Late Life During the Physical Assessment: Mouth

Excessive dryness is common and exacerbated by many medications. Cannot use mouth moisture to estimate hydration status. Periodontal disease is common. Decreased sense of taste occurs. Tooth surface may be abraded.

Preventing Iatrogenesis

Expect iatrogenesis among your residents. Identify residents at high risk for iatrogenesisd that is, older adults who are aged 80 years or older, are frail, have multiple physical and cognitive comorbidities, and have new-onset geriatric syndromes. Educate the resident and family, to the extent possible, about where they are at risk, what is being done to minimize that risk, and the things they need to do to remain hale and hearty. Dispel the myths of aging among residents, family, and staff. Develop a proactive approach to prevention and recognition of iatrogenesis, recognizing that the early warning signs may be fragmented. Monitor and communicate unexplained signs, symptoms, and complaints.5 Develop, foster, and maintain a blame-free culture of safety so that when an iatrogenic event does occur, its origin and resolution can be better understood and managed.

Falls

Falls are a leading cause of serious injury in older people. There are many risk factors for falling, including safety hazards in the home, medication side effects, walking and vision problems, dizziness, arthritis, weakness, and malnutrition. Like other geriatric syndromes, falls usually have more than one cause. -Tell your healthcare provider immediately if you have fallen. They will look into what caused your fall and suggest steps to prevent future falls. There are many treatments, such as exercise and physical therapy, that can help improve your gait and walking and prevent falls. (Common And Often Related Medical Conditions In Older Adults)

Fall Risk Factors

Falls are a symptom of a problem and are rarely benign in older people. The etiology of falls is multifactorial; falls may indicate neurological, sensory, cardiac, cognitive, medication, or musculoskeletal problems or impending illness. Episodes of acute illness, infection, or exacerbations of chronic illness are times of high fall risk -Majority occur from a combination of intrinsic and extrinsic factors that combine at a certain point in time -Events above are times of high fall risk

Dietary Recommendations for older adults: fiber

Fiber is an important dietary component that some older people do not consume in sufficient quantities. A daily intake of 25 g of fiber is recommended and must be combined with adequate amounts of fluid. Insufficient amounts of fiber in the diet, as well as insufficient fluids, contribute to constipation. Fiber is the indigestible material that gives plants their structure. It is abundant in raw fruits and vegetables and in unrefined grains and cereals.

Conducting Mental Status Examinations and Evaluations

First, the professional nurse approaches the patient respectfully, asking him or her to participate in the examination. In all likelihood, the examination will be completed in approximately 10 minutes. With this approach, the nurse helps establish the necessary rapport with the patient. If the nurse callously or capriciously approaches an elderly patient, there is an increased risk the patient may refuse to participate in the assessment.

Fluent (Wernicke's) Aphasia

Fluent aphasia is caused by damage to a part of the brain adjacent to the primary auditory cortex (Wernicke's area). In some cases the person may not be able to speak. More often the person speaks easily with many long runs of words, but the content does not make sense. They have problems finding the correct word and often substitute an incorrect word without realizing it. The speech sounds like what is sometimes referred to as "jabberwocky," with unrelated words strung together or syllables repeated. The person may be unaware of his or her speech difficulties and cannot understand why others do not understand.

Pender's health promotion model

Focuses on promoting health and managing stress -people want to live in ways that will enable them to be as healthy as possible -increasing coping by increasing physical activity, better nutrition

Need-driven dementia-compromised behavior

Focusing on looking at behaviors seen in a patient with dementia and why they are exhibiting them -All behaviors have meaning and are a form of communication -Behavior reflects the interaction of background and proximal factors with social environment

Formal Sources of Care

Formal care may occur in both the institutional and home settings. Formal care is either paid for privately with personal funds, long-term care insurance, or through government programs such as Medicaid, or Medicaid Waiver Programs

Assessing Frailty

Frailty is loosely defined as evidence of three of the following: unexplained weight loss, self-reported exhaustion, weak grip strength, slow walking speed, and low activity. It is better to ask specifically about each one of these symptoms. Many people consider the signs as "just a normal part of aging." To provide a method of quantifying frailty to the extent possible, a number of scales have been developed and some of them tested. Most are available free of charge for educational and professional practice use.

Other Symptoms Experienced by People With Parkinson's Disease

Frequent changes in body temperature Problems with blood pressure Dizziness Fainting Frequent falls Sensitivity to heat and cold Sexual dysfunction Urinary incontinence Constipation Poor sense of smell Sialorrhea (drooling)

Erik Erikson

Freud had a strong influence on his psychoanalytical followers, including Erik Erikson (1902-1994), who constructed a theory of development that differed from Freud's in one main aspect: Erikson's stages emphasize a person's relationship to family and culture rather than sexual urgess.

Advance Care Planning

Gerontological nurses have the responsibility to encourage their patients, neighbors, and family members to discuss their wishes regarding potential incapacity, otherwise referred to as advance care planning. It is always advisable to appoint a legal surrogate or proxy and formally document one's wishes.

Dysphagia Interventions

Goal: Safe oral intake to maintain optimal nutrition and caloric needs Compensatory interventions include -Postural changes and proper positioning -Modification of bolus volume, consistency, temperature, and rate of presentation -Modified diets Neuromuscular electrical stimulation

Living arrangements of the elderly: 1800-1900s

HISTORICALLY -Elders controlled family & property (older males) -Poor, widowed, unmarried lived in family home -Lived with adult children Elders as burden (in US) -Alms houses, workhouses, poor farms -County farms -"put out to pasture"

Aging Changes: Hair and Nails

Hair: changes depend on genetics. thinning of hair on head and increased hair in ears, nose and eyebrows, hair pigmentation loss (grey hair). women may develop chin hair, and see decrease in hair on legs, underarms and pubic areas Nails become harder, thicker, dull and more brittle, flatter, vertical ridges can appear, fungal infections often occur

Considerations of Common Changes in Late Life During the Physical Assessment: Hearing

High-frequency hearing loss (presbycusis) is common. The person often complains that he or she can hear but not understand because some, but not all, sounds are lost. The person with severe but unrecognized hearing loss may be incorrectly thought to have dementia.

Consequences of Falls

Hip fracture -More than 95% of hip fractures among older adults are caused by falls -Associated with considerable morbidity and mortality Traumatic brain injury (TBI) -Falls are the leading cause of TBI for older adults Fallophobia -Loss of confidence that leads to decrease in physical activity in general and more socially withdrawn; increases dependency -An important predictor of general functional decline and a risk factor for future falls

Resident Assessment Instrument (RAI)/Minimum Data Set (MDS 3.0)

In 1986 the Institute of Medicine (IOM; now called the Health and Medicine Division of the National Academy of Medicine) completed a study indicating that although considerable variation existed, residents in skilled nursing facilities in the United States were receiving an unacceptably low quality of care (IOM, 1986). As a result, nursing home reform was legislated as part of the Omnibus Budget Reconciliation Act (OBRA) of 1987. The creators of OBRA recognized the challenging work of caring for increasingly ill persons discharged from acute care settings to nursing homes and, along with this, the need for comprehensive assessments, complex decision-making, and documentation regarding the care that was needed, planned, implemented, and evaluated. In 1990 a Resident Assessment Instrument (RAI) was created and mandated for use in all skilled nursing facilities that receive compensation from either Medicare or Medicaid. In March 2014, Quality Measures were updated to provide a standardized measure of the quality of care provided. This includes consideration of 992 different measures, ranging from postoperative infection to fall prevention strategies.

The Mini-Cog

In some settings the use of the Mini-Cog has replaced the MMSE as a screening tool for cognitive impairment. It has been found to be as accurate and reliable as the MMSE but less biased, easier to administer, and possibly more sensitive to dementia. The Mini-Cog combines the test of short-term memory in the original MMSE with the Clock Drawing Test. It has been found to be equally reliable with English-speaking and non-English-speaking individuals. It serves as an indicator of the need for more detailed assessments leading to diagnosis. It requires the same basic skills as the Clock Drawing Test. 1. Name three objects and ask person to repeat them (3 tries max) 2. Do clock drawing test (next slide) 3. Have them repeat the objects again Score ◦0 recall- indication of dementia ◦0-2 recall- indication of dementia ◦3-5 recall- no indication

Alcohol Use Disorder: Prevalence and Characteristics

In the United States, alcohol use disorders are reported in 11% of adults aged 54 to 64 years and about 6.7% of those older than 65 years. Two-thirds of elderly alcoholics are early-onset drinkers (alcohol use began at age 30 or 40), and one-third are late-onset drinkers (use began after age 60). Late-onset drinking may be related to situational events such as illness, retirement, or death of a spouse and includes a higher number of women. Most severe alcohol abuse is seen in people ages 60 to 80 years, not in those older than 80 years. Alcoholism is the third most prevalent psychiatric disorder (after dementia and anxiety) among older men. The prevalence of alcohol abuse among older adults who are hospitalized for general medical and surgical procedures and institutionalized elders is approximately 18%. Alcohol-related problems in the elderly often go unrecognized, although the residual effects of alcohol abuse complicate the presentation and treatment of many chronic disorders of older people.

Self-report

In the self-report format, either questions are asked directly or the person is expected to respond to written questions about his or her health status. Patients tend to overestimate their own abilities, and older adults in particular have been found to under-report symptoms, often because of the erroneous belief that their symptoms are normal parts of aging.

Discussion

In this section the author interprets the results of the study. The meaning of the data collected and analyzed is explained, as well as how the data answer (or do not answer) the research question(s). Limitations to the study (e.g., Are there particular populations to which the results do not apply? Are there factors not part of the study design that may have influenced the outcome of the study?) and what additional research is needed also are discussed. Many research articles have an application to practice section that suggests ways in which the results can be used in everyday practice.

Guardians and Conservators

Individuals, agencies, or corporations that have been appointed by the court to have care, custody, and control of a disabled person to manage his or her financial responsibilities guardian: appointed to be responsible for another person conservator: appointed for finances

Nursing Interventions: RETIREMENT

Interventions that demonstrate effective care for an individual who has expressed a wish to "retire sometime soon": -Asking when the person plans to retire -Scheduling a complete physical exam -Assessing their ability to handle the stresses of retirement -Engaging them in a conversation about their interests -Inquiring about the existence of any chronic illnesses

Factors contributing to falls

Intrinsic factors (more common the more someone ages) -Reduced vision and hearing -Unsteady gait -Cognitive impairment -Acute and chronic illnesses -Effects of medication Extrinsic factors (more common in the younger old and healthier old) -Lack of support equipment in the bathtub and at the toilet -Height of the bed -Floor conditions -Poor lighting -Inappropriate footwear -Improper or inadequate assistive devices

Person-Centered Care

Irreversible NCDs have no cure, and although new medications offer hope for improved function, the most important treatment treatment for the disease is competent and compassionate person-centered care. Person-centered care is one of the six major aims in the redesign of the U.S. health care system and considers "what matter most" to individuals. Long ago, Mary Opal Wolanin, a gerontological nursing pioneer, suggested that nurses are not as interested in the neurofibrillary tangles in the brain as they are in trying to smooth out the environmental and relational tangles the person and his or her loved ones experience. "Since Alzheimer's affects mind and personality, as well as physical function, there is a great danger that the person can become obscured by the disease, defined by symptoms rather than by her or his unique spirit and continuing sense of self". The focus in person-centered care is not on what we need to do to the person but on the person himself or herself and how to enhance well-being and quality of life.

C—Communication

Is the person able to communicate his or her needs adequately? Do the persons who provide care understand the patient's form of communication? What is the person's ability to hear in various environments? Are there any situations in which understanding of the spoken word is inadequate? If the person depends on lip-reading, is his or her vision adequate? Is the person able to clearly articulate words that are understandable to others? Does the person have either expressive or receptive aphasia, and if so has a speech therapist been made available to the person and significant others? What is the person's reading and comprehension levels? The impoverished childhoods of some individuals and the racist educational practices for others, even in developed countries, have resulted in very low or no literacy levels in these groups. It is best to assume that an elder's literacy is no greater than at a fifth-grade level in most settings. Inadequate assessment of communication by the nurse will lead to erroneous conclusions and significantly reduce the quality of care.

P—Pain

Is the person experiencing physical, psychological, or spiritual pain? Rarely does one type of pain occur in isolation. Is the person able to express pain and relief of pain? Are there cultural barriers between the nurse and the patient that make the assessment or expression of pain difficult? Do cognitive limitations provide further barriers? How does the person customarily attain pain relief? As a result of the increasing amount of pain common with each decade of life (e.g., progression of arthritis or number of losses), this deserves particular attention by gerontological nurses.

Neuroplasticity

It is very important to know that the aging brain maintains resiliency or the ability to compensate for age-related changes. Developing knowledge refutes the myth that the adult brain is less plastic than the child's brain and less able to strengthen and increase neuronal connections. The old adage "use it or lose it" applies to cognitive and physical health. Stimulating the brain increases brain tissue formation, enhances synaptic regulation of messages, and improves the development of cognitive reserve (CR).

The LEARN model

L: listen (verbal and nonverbal) E: explain (your perception) A: acknowledge (similarities and differences between your perceptions) R: recommend (plan of action) N: negotiate (plan)

Bladder Control Problems

Lack of bladder control, or "urinary incontinence," is an embarrassing topic. Please know that you are not alone! Urinary incontinence can lead to problems such as falls, depression, and isolation. In most cases, incontinence can be cured or greatly improved with treatment. So don't hesitate to tell your healthcare provider if you have bladder control problems. (Common And Often Related Medical Conditions In Older Adults)

Crisis Prone:

Lacks or believes it lacks control over its environments

Considerations of Common Changes in Late Life During the Physical Assessment: Eyes

Lids sag and position of lids may change. Reduced pupillary responsiveness (miosis) occurs (normal if equal bilaterally). Gray ring around the iris (arcus senilis) may develop.

Considerations of Common Changes in Late Life During the Physical Assessment: Heart

Listen carefully for third and fourth heart sounds. Faint fourth heart sounds may be heard. Determine if this was present in the past or is new. Up to 50% of persons have a heart murmur.

Injury and Cognitive Impairment

Little is known about the role of cognitive impairment in injury presentations or etiology. Because of the nature of the pathological process, persons with cognitive impairments may experience unique or an increased rate of injuries related to wandering, behavioral symptoms, and problems with judgment16; thus, they may be more likely to sustain falls or experience accidental injury. Moreover, persons with cognitive impairment are thought to be at a greater risk for elder abuse then the general older adult population; however, little is known about injuries from elder abuse in this population.

Death of a Spouse or Life Partner

Losing a spouse or other life partner after a long, close, and satisfying relationship is the most difficult adjustment one can face, aside from the loss of a child. This loss is a stage in the life course that can be anticipated but seldom is considered. Spousal bereavement in later life is a high probability for women and, while less common among men, still a significant event. The death of a life partner is essentially a loss of self. The mourning is as much for oneself as for the individual who has died. A core part of oneself has died with the partner, and even with satisfactory grief resolution, that aspect of self will never return. Even those widows and widowers who reorganize reorganize their lives and invest in family, friends, and activities often find that many years later they still miss their "other half" profoundly.

Rapid Eye Movement Sleep Behavior Disorder

Loss of voluntary muscle atonia during REM sleep -Violent behaviors while dreaming -Treatment: Medication (Clonazepam) and safety measures

Carroll: Assessment of Capacity for Medical Decision Making

Main points: ◦Autonomy to make decisions about the medical care we receive is a basic human right ◦Capacity is a measure of a person's ability to make an informed & logical decision about health care ◦If person lacks capacity, a surrogate (substitute) must be appointed Implications for nurses: we have a role in helping determine a person's capacity to make health care decisions

Integrity vs. Despair

Many older adults review their lives with a sense of satisfaction, even with their inevitable mistakes. Others see themselves as failures, with their lives marked by despair and regret. Older adults often engage in a retrospective appraisal of their lives. They interpret their lives as a meaningful whole or experience regret because of goals not achieved. Because the aging process creates physical and social losses, some adults also suffer a loss of status and function. These external struggles are met with internal struggles, such as the search for meaning in life. Meeting these challenges creates the potential for growth and the basic strength of wisdom Integrity: able to look back in your life and be satisfied Self-despair: unfulfilled, lack of purpose (Erikson)

Jester role:

Many people with dementia retain their sense of humor and respond well to the appropriate use of humor. This does not mean making fun of the person but rather sharing laughter and fun. "Those who love their work and do it well employ good doses of humor as part of the care of others, as well as for self-care". The jester spreads joy, is creative, energizes, and lightens the burdens

Reducing Osteoporosis-Related Risk and Injury

Measures to prevent osteoporosis-related injury or progression of the disease include exercise, nutrition, and lifestyle changes to reduce known risk factors. As with many other diseases, smoking is one risk factor that can be changed. Home safety inspection and education regarding injury prevention strategies are essential

Considerations of Common Changes in Late Life During the Physical Assessment: Genitourinary male

Men have pendulous scrotum with less rugae. Have thin and graying pubic hair.

Mental Health in Later Life

Mental health is not different in later life, but the level of challenge may be greater. Developmental transitions, life events, physical illness, cognitive impairment, and situations calling for psychic energy may interfere with mental health in older adults. These factors, though not unique to older adults, often influence adaptation. However, anyone who has survived 80 or so years has been exposed to many stressors and crises and has developed tremendous resistance. Most older people face life's challenges with equanimity, good humor, and courage. It is our task to discover the strengths and adaptive mechanisms that will assist them to cope with the challenges.

Mission of The Minnesota Elder Justice Center

Mobilizing communities to prevent and alleviate abuse, neglect, and financial exploitation of elders and vulnerable adults.

Considerations of Common Changes in Late Life During the Physical Assessment: Height and weight

Monitor for changes in weight. Weight gain: Especially important if the person has any heart disease; be alert for early signs of heart failure. Weight loss: Be alert for indications of malnutrition from dental problems, depression, or cancer. Check for mouth lesions from ill-fitting dentures.

Hip Fractures

More than 95% of hip fractures among older adults are caused by falls. Hip fracture is the second leading cause of hospitalization for older people, occurring predominantly in older adults with underlying osteoporosis. Hip fractures are associated with considerable morbidity and mortality. Recovery from hip fractures is complicated by the presence of multiple comorbid conditions and potentially avoidable problems such as weight loss, delirium, pain, falls, and incontinence. Only 50% to 60% of patients with hip fractures will recover their prefracture ambulation abilities in the first year postfracture. Older adults who fracture a hip have a five to eight times increased risk of mortality during the first 3 months after hip fracture. This excess mortality persists for 10 years after the fracture and is higher in men. Most research on hip fractures has been conducted with older women, and further studies of both men and racially and culturally diverse older adults are necessary.

Interventions for those with delirium or dementia

Most interventions are part of good nursing care Focuses on managing ◦Cognitive impairment ◦Sleep deprivation ◦Immobility ◦Visual impairments ◦Hearing impairments ◦Dehydration Antipsychotic drugs should not be routinely used

Problems with Eating or Feeding

Most nutritional issues are associated with a disease or illness, but other causes include dietary restrictions, oral cavity and denture issues, medications, reduced sense of smell and taste, and inability to carry food and fluid to the mouth.12 Many eating or feeding problems in older adults can be severe. Nutritional assessment includes diet(ary) history (e.g., previous interventions that were successful as well as unsuccessful) and oral cavity examination. Individuals who are overweight (i.e., body mass index [BMI] . 25) are as at risk for malnutrition as those who are underweight (i.e., BMI \ 19).12 Both can have loss of muscle mass and a compromised immune system. The Mini Nutritional Assessment can identify older adults at risk for malnutrition.12 Information about the older adult's culture, food preferences, and social customs with regard to eating, as well as lab work and a 72-hour food diary, should be part of the assessment.

Resiliency in older adults

Most older adults manage transitions and stressors through resilience, hardiness, and resourcefulness

Frailty

Most older adults who live to an advanced age will become frail. Not really a disease, frailty is a combination of age-related changes and assorted medical problems. Eluding precise definition, the "Fried framework" suggests that an individual having 3 or more of the following conditions should be considered frail: exhaustion, unintentional weight loss of more than 10 pounds in 1 year, muscle weakness, walking slowly, and low physical activity level. Research indicates that frailty is a reliable indicator of imminent decline in health status and includes falls, reduced mobility, low functional reserve, easy tiring, and high susceptibility to disease. Certain diseases and medical conditions are associated with frailty, including anorexia, sarcopenia, atherosclerosis, impaired balance, mood disturbance (depression), and cognitive impairment.

Aging Changes: Gastrointestinal (GI)

Mouth -teeth can lose enamel and dentin (more vulnerable to decay) -taste buds decline -salivary secretion lessens leading to dry mouth -gums can recede leading to greater risk of oral and heart disease Stomach -More sluggish, empty slower, increasing risk of gird -Decrease in gastric motility, will feel full faster -Decreased ability to produce intrinsic factor Intestines -Villi lower functioning affecting absorption and nutrients -Slowing peristalses -Constipation Liver -Reduced blood flow which affects medication solubility Gallbladder -Increased risk of gallstones

5 Myths About Aging

Myth 1: You'll Sleep Poorly Myth 2: You'll Become Frail Myth 3: You Will Have No Interest in Sex Myth 4: Confusion and Memory Loss Are the Norm Myth 5: You'll Become Lonely and Depressed

Communicating with someone with dementia

Need to communicate and be treated as a person remain despite memory and communication impairments Strategies ◦Simplification, used with activities of daily living (ADLs) - one-step directions ◦Facilitation, encouraging thoughts and feelings - sharing things, broad openings ◦Comprehension, understanding communication ◦Supportive ◦NOT reality orientation, but gentle reminders

Neglect by a Caregiver

Neglect by a caregiver requires a socially (formally or informally) recognized role and responsibility of a person to provide care to a vulnerable other. Neglect is most often passive mistreatment, such as an act of omission. It is not only the failure to provide the goods and services—such as food, medication, medical treatment, and personal care—necessary for the well-being of the frail elder, but also the failure or inability to recognize the responsibility to provide such goods and services. Neglect is active when care is withheld deliberately and for malicious reasons. In some cases this level of neglect would be considered abuse as well. Neglect by caregivers occurs for many reasons.

Sexual Abuse

Nonconsensual sexual contact or activity of any kind; coercing an elder to witness sexual behaviors Ex: Unwanted touching, rape, sodomy, forced watching of pornography, coerced nudity, sexually explicit photography

Nonfluent (Broca's) Aphasia

Nonfluent aphasia typically involves damage to the Broca's area. The person usually understands others but speaks very slowly and uses minimal numbers of words. The person often struggles to articulate a word and seems to have lost the ability to voluntarily control the movements of speech. Difficulties are experienced in communicating both orally and in writing.

nonmodifiable risk factors

Nonmodifiable risk factors such as age, gender, genetics, and family history cannot be changed. You use your understanding of nonmodifiable risk factors to select appropriate secondary prevention strategies. For example, a person's age increases the susceptibility to certain illnesses and accidents.

Nurse Evaluation of Pain

Nurse pt family all work together with meds and non pharm treatment. Need continual reassessment. Use same instruments for objective measures. treatment often multimodal. Draw on what has worked for them in the past

Physical Assessment

Nurses learn to conduct a complete "head-to-toe" when conducting a physical assessment. Although this is usually done when assessing younger persons, it is rarely possible when working with an older adult, especially one who is medically complex or fragile. To do so would be excessively time-consuming and burdensome to all involved. Instead the assessment is first directed to that which is most likely associated with the presenting problem or major diagnoses and progresses from there. When performing a physical assessment the gerontological nurse must be able to quickly prioritize what is the most necessary to know (based on the chief complaint) and proceed to what would be "nice to know."

Variability Among Older Adults

Nursing care of older adults poses special challenges because of variations in their physiological, cognitive, and psychosocial health. Older adults also have a wide range of functional ability. Most older adults are active and involved in their communities. A smaller number have lost the ability to care for themselves, are confused or withdrawn, and/or are unable to make decisions concerning their needs. Most older adults live in noninstitutional settings.

Why does a nurse need to know about financial issues of the older adult patient?

Nursing roles: advocate, educator, counselor, direct care provider and maker of referrals to experts •Help older adults avoid scams related to insurance, costs of care •Provide basic information on what payment sources will cover (Medicare—A, B, and D, Medicaid, TRICARE, long-term care insurance) •Identify resources to help older patients deal with financial issues •Help older adults identify questions that they have about financing health care and understand what they were told

Pain Assessment

OLDCART (onset, location, duration, characteristics, aggravating factors, relieving factors, treatment) assessment tool -History and physical examination related to pain -Pain scales for those with cognitive impairments for treatment and those medications that have been tried -Medications -Pain scales

Physical Abuse

Occurs when older adults experience illness, pain, or injury as the result of physical force or the threat of physical injury. Ex: Hitting, beating, pushing, slapping, kicking, physical restraint, inappropriate use of drugs, fractures, lacerations, rope burns, untreated injuries

Traumatic Brain Injury (TBI)

Older adults (75 years of age and older) have the highest rates of traumatic brain injury (TBI)-related hospitalization and death. Falls are the leading cause of TBI for older adults. Advancing age negatively affects the outcome after TBI, even with relatively minor head injuries. A CDC initiative, Help Seniors Live Better Longer: Prevent Prevent Brain Injury, provides educational resource materials on TBI for older adults, caregivers, and health care professionals in both Spanish and English

Older adults and pain

Older adults can have a delayed response in their recognition to pain-decreased tactile sensation and delayed reaction time.

Exercise Guidelines for older adults

Older adults need at least: • 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (e.g., brisk walking, swimming, bicycling) every week and •Muscle-strengthening activities on 2 or more days that work all major muscle groups (legs, hips, abdomen, chest, shoulders, and arms)

Alcohol Use Disorder: Physiology

Older people, especially females, develop higher blood alcohol levels because of age-related changes (increased body fat, decreased lean body mass, and total body water content) that alter absorption and distribution of alcohol. Decreases in hepatic metabolism and kidney function also slow alcohol metabolism and elimination. A decrease in the level of the gastric enzyme alcohol dehydrogenase results in slower metabolism of alcohol and higher blood levels for a longer time. Risks of gastrointestinal ulceration and bleeding related to alcohol use may be higher in older people because of the decrease in gastric acidity that occurs in aging.

Medication Use in Older Adults

One of the greatest challenges for older adults is safe medication use. Medication categories such as analgesics, anticoagulants, antidepressants, antihistamines, antihypertensives, sedative-hypnotics, and muscle relaxants create a high likelihood of adverse effects in older adults. They are at risk for adverse medication effects because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs, collectively referred to as the process of pharmacokinetics. Medications sometimes interact with one another, adding to or negating the effect of another drug. Examples of adverse effects include confusion, impaired balance, dizziness, nausea, and vomiting. Because of these effects, some older adults are unwilling to take medications; others do not adhere to the prescribed dosing schedule, or they try to medicate themselves with herbal and over-the-counter medications.

Considerations of Common Changes in Late Life During the Physical Assessment: Musculoskeletal

Osteoarthritis is very common and pain is often undertreated. Ask about pain and function in joints. Conduct very gentle passive range of motion if active range of motion not possible. Do not push past comfort level. Observe for gait disorders. Observe the person get in and out of chair in order to assess independent function and fall risk.

alendronate (Fosamax)

Osteoblastic medications—stimulates bone formation & inhibit bone resorption Adverse effects—esophagitis PO—poorly absorbed and not absorbed if taken with food, calcium, magnesium, iron ◦Administration: in AM 30 minutes before meal ◦With 8 oz water ◦Stay upright for at least 30 minutes after taking ◦Low dosage—daily or higher dose weekly BIPHOSPHONATE

Osteoporosis

Osteoporosis, or "thinning bones," is a condition that makes the bones of older adults more fragile and easy to break. Women 65 and older, and men over age 70, should get a bone mass density (BMD) test. Increased calcium and vitamin D intake, strength training exercises, and weight-bearing exercises such as walking are important to keeping your bones healthy. Your healthcare provider may also recommend medications or other treatments. (Common And Often Related Medical Conditions In Older Adults)

Osteoporosis Treatment/Vitamin D Supplementation

Other potential interventions for fall risk reduction include assessment and treatment of osteoporosis to reduce fracture rates. Older people with osteoporosis are more likely to experience serious injury from a fall. The American Geriatrics Society recommends vitamin D supplementation of at least 1000 international units, as well as calcium supplementation, to community-dwelling and older adults residing in institutionalized settings to reduce the risk of fractures and falls

Memory

Our ability to retain and store information and then get it back when we want it -familiarity, previous learning, and life experiences can compensate for memory loss

Components of the PFA

PFAs include a fall-focused history; fall circumstances; medical problems; medication review; mobility assessment; vision and hearing assessment; neurological examination (including cognitive assessment); and cardiovascular assessment (orthostatic blood pressure [BP], cardiac rhythm irregularities). If the older adult cannot tell you about the circumstances of the fall, information should be obtained from staff or witnesses. Because complications of falls may not occur immediately, all patients should be observed for 48 hours after a fall and vital signs and neurological status monitored for 7 days or more, as clinically indicated. Standard "incident report" forms do not provide adequate postfall assessment information. The Department of Veterans Affairs National Center for Patient Safety provides comprehensive information about fall assessment, fall risk reduction, and policies and procedures

Pain in Older Adults

Pain is a symptom and a sensation of distress, alerting a person that something is wrong. It is prevalent in the older-adult population and may be acute or chronic. The consequences of persistent pain include depression, loss of appetite, sleep difficulties, changes in gait and mobility, and decreased socialization. Many factors influence the management of pain, including cultural influences on the meaning and expression of pain for older adults, fears related to the use of analgesic medications, and the problem of pain assessment with older adults who are cognitively impaired. Nurses caring for older adults have to advocate for appropriate and effective pain management. Again, the goal of nursing management of pain in older adults is to maximize and maintain function and improve quality of life.

pain assessment in an older adult

Pain is an accepted part of the aging process May avoid giving an accurate assessment of pain for fear of losing independence Sensory and cognitive impairment may make communication and pain assessment more difficult VDS may be the most sensitive and reliable among older adults Scales rely on the patients ability to understand the scale and communicate a response

Pelvic floor muscle exercises

Pelvic floor muscle exercises (PFMEs), also called Kegel exercises, involve repeated voluntary pelvic floor muscle contraction. The targeted muscle is the pubococcygeal muscle, which forms the support for the pelvis and surrounds the vagina, the urethra, and the rectum. The goal of the repetitive contractions is to strengthen the muscle and decrease UI episodes. PFMEs are recommended for stress, urge, and mixed UI in older women and have also been shown to be helpful for men who have undergone prostatectomy. In community-dwelling older adults, PFMEs are at least as effective as medications in treating stress and urge UI. Biofeedback may improve PFME teaching and outcomes, but further research is needed. Medicare covers biofeedback for individuals who do not improve after 4 weeks of a trial of PFMEs.

Nursing role in falls

Perform an initial fall assessment on admission, after any change in condition, and at regular intervals during a stay: -Assessment of the older adult at risk -Nursing assessment of the patient after a fall -Assessment of the environment and other situational circumstances upon admission and during institutional stays -Assessment of the older adult's knowledge of falls and their prevention -Fall risk assessment is an integral part of primary health care for the older person -Adults may be apprehensive about sharing information regarding a fall because of the fear of losing their independence -Screening tools can be used to determine the risk for falling

Three Phases of the TeamSTEPPS Delivery System

Phase 1—Assess the Need Phase 2—Planning, Training, and Implementation Phase 3—Sustainment

Phase 2—Planning, Training, and Implementation

Phase 2 is the planning and execution segment of the TeamSTEPPS initiative. Because TeamSTEPPS was designed to be tailored to the organization, options in this phase include implementation of all tools and strategies in the entire organization, a phased-in approach that targets specific units or departments, or selection of individual tools introduced at specific intervals (called a "dosing strategy" in TeamSTEPPS parlance). As long as the primary learning objectives are maintained, the TeamSTEPPS materials are extremely adaptable.

Symptoms of Depression

Physical symptoms ◦Insomnia ◦Loss of appetite and weight loss ◦Memory loss and cognitive impairment ◦Chronic pain Hypochondriasis Decreased energy and motivation

Steps of Changing Health Behaviors

Precontemplation: not planning to make a change in the next 6 months Contemplation: considering making a change in the next 6 months Preparation: making small changes; maybe in next month might make change Action: start making the change Maintenance: sustained change over time (6+ months)

What if you suspect abuse or neglect?

Priority is to find out if safe in current living situation -know how to report suspected abuse -think about if stress of patient or family member can be lessened

Long-Term Care Insurance

Provides payment for extended nursing care due to accidents, illness, or old age •Becoming innovative •Once limited to care in LTC facilities •May now cover home care costs instead •Or both LTC and home care •Premiums can be very high •Ideally, these policies would cover expenses related to co-pays for long-term care and coverage for custodial care or help with day-to-day needs (as opposed to skilled care) •Purchaser is cautioned to read policies carefully about what conditions and cost are covered

Developmental Theory

Psychologist Erik Erikson's theory of psychosocial development is one of the best known theories of personality in psychology. He theorized a predetermined order of developmental and specific tasks that were associated with specific periods in one's life course. The task of the last stage of life is ego integrity versus self-despair.

Aging and DNA

ROS and free radicals don't trigger process on their own. DNA mutations occur

Free Radical Theory

Radicals (natural bioproducts of cell) are always present. When young we have things such as hormones that make the radicals not dangerous. As we age we can no longer keep up with the free radicals in our body and they can begin to cause damage

Neglect

Refusal or failure by those responsible to meet basic needs Ex: Refusal or failure to provide basic necessities such as food, water, shelter, hygiene, and medical care

Activity

Regular physical activity throughout life is essential for healthy aging Recommendations? -2.5 hours weekly moderate activity -2 days of muscle-strengthening -Stretching and balance exercises

Religion

Religion is associated with the "state of doing," or a specific system of practices associated with a particular denomination, sect, or form of worship. It is a system of organized beliefs and worship that a person practices to outwardly express spirituality. Many people practice a faith or belief in the doctrines and expressions of a

Obesity Paradox

Research shows that people over 70 have a lower mortality rate if considered overweight -unclear if true

Restraint-Free Care

Restraint-free care is now the standard of practice and an indicator of quality care in all health care settings, although transition to that standard is still in progress, particularly in acute care settings. Physical restraint use in acute care is now predominantly in intensive care units (ICUs), particularly for patients with medical devices and those with delirium. Older adults with delirium have higher risks of being restrained than other patients. Both the American Geriatrics Society and the American Board of Internal Medicine recommend that physical restraints should not be used to manage behavioral symptoms of hospitalized older adults with delirium

SPICES Tool for Overall Assessment of Older Adults

S: Sleep disorders P: Problems with eating or feeding I: Incontinence C: Confusion E: Evidence of falls S: Skin breakdown The nurse should complete further assessment if an older adult demonstrates changes in any of these areas

Parkinsons Nursing considerations and goals

SAFETY, MOVEMENT, COMFORT •Maintain/Improve: -functional mobility -independence in ADLs -Bowel management -Nutritional status -Effective communication •Avoid injury •Develop positive coping mechanisms

Mini Nutritional Assessment (MNA)

Screening tool which evaluates 1. Independence 2. Medications 3. Number of full meals consumed 4. Protein intake 5. F & V 6. Fluid 7. Mode of feeding In individuals >/=65 YO Acquire a minimum data set, a food and nutrient intake, 24 hr dietary recall or 3 day dietary history

Second Generation Theories

Second-generation theories expanded or questioned those of the first generation. These include the disengagement, continuity, age-stratification, social exchange, modernization, developmental, and gerotranscendence theories.

Role Theory

Self identity is believed to be defined as ones role in society (nurse teacher mailman). Successful would mean that as one completes one role, they replace it with another. From nurse, to volunteer to grandma/pa. Based primarily on culturally constructed expectations.

Restless leg syndrome

Sensorimotor neurologic disorder with leg sensations Symptoms: -Paresthesia -Creeping/crawling sensations -Tingling - Cramping -Burning -Pain Treatment: -Medications -Non-medications

UI Lifestyle modifications

Several lifestyle factors have been associated with either the development or the exacerbation of UI. These include increased fluid intake, smoking cessation, bowel management, physical activity, and weight reduction. Research has shown that women with stress UI who undergo a 5% to 10% weight loss experience a positive impact on UI symptoms. This is most likely due to the effects of reduced abdominal weight, intra-abdominal pressure, and intravesicular pressure

Side Rails

Side rails are no longer viewed as simply attachments to a patient's bed but are considered restraints with all the accompanying concerns just discussed. Side rails are now defined as restraints or restrictive devices when used to impede a person's ability to voluntarily get out of bed and the person cannot lower them by themselves. Restrictive side rail use is defined as two full-length or four half-length raised side rails. If the patient uses a half- or quarter-length upper side rail to assist in getting in and out of bed, it is not considered a restraint. CMS requires nursing homes to conduct individualized assessments of residents, provide alternatives, or clearly describe the need for restrictive side rails

motor signs and symptoms of parkinsons

Signs and symptoms begin slowly; therefore Parkinson's disease is difficult to diagnose Four major motor signs 1.*(SHAKY) Resting tremor 2.(STIFF) Muscular rigidity 3.(SLOW) Bradykinesia 4. Asymmetric onset stooped

Dietary Recommendations for older adults: fats

Similar to other age groups, older adults should limit intake of saturated fat and trans fatty acids. High-fat diets cause obesity and increase the risk of heart disease and cancer. Recommendations are that 20% to 35% of total calories should be from fat, 45% to 65% from carbohydrates, and 10% to 35% from proteins. Monounsaturated fats, such as olive oil, are the best type of fat because they lower low-density lipoprotein (LDL) level but leave the high-density lipoprotein (HDL) level intact or even slightly raise it.

Sleep Problems

Sleep problems can affect your quality of life and can contribute to falls, injuries, and other health problems. If you have trouble sleeping at night or feel sleepy during the day, tell your healthcare provider so they can identify the type of sleep problem you have. (Common And Often Related Medical Conditions In Older Adults)

S—Socialization and Social Skills

Socialization and social skills include the individual's ability to negotiate in society, to give and receive love and friendship, and to feel self-worth. The selection of persons included in one's social network is highly culturally influenced. Assessment focuses on the individual's ability to deal with loss and to interact with other people in give-and-take situations.

Modifiable risk factors

Some risk factors such as lifestyle practices and behaviors can be modified. Modifiable risk factors include poor nutrition, overeating, and insufficient rest and sleep. Some risk factors put a person at risk for developing specific diseases. For example, excessive sunbathing increases the risk of skin cancer; smoking increases the risk of lung diseases, including cancer; and a poor diet and being overweight increase the risk of cardiovascular disease.

Internal resources of older adults

Spirituality, culture, coping skills, decision-making

Stages of pressure ulcers

Stage I: nonblanchable erythema of intact skin Stage II: partial-thickness skin loss Stage III: full-thickness skin loss; not involving underlying fascia Stage IV: full-thickness skin loss with extensive destruction Unstageable: base of ulcer covered by slough and/or eschar in wound bed

Substance Use Disorders

Substance use disorders among older adults are a growing public health concern. With the aging of the baby boomer generation, the number of adults older than age 50 with substance abuse problems is projected to double by 2020. The baby boomer generation has had more exposure to alcohol and illegal drugs in their youth and has a more lenient attitude about substance abuse. Additionally, psychoactive drugs became more readily available for dealing with anxiety, pain, and stress. The use of illicit drugs, such as cocaine, heroin, and marijuana, is becoming more prevalent, and baby boomer marijuana users will triple in the next decades.

Surgical Treatment of UI

Surgical interventions may be indicated for stress UI and have a high cure rate. The most common procedures are colposuspension (Burch operation) and slings. Surgical suspension of the bladder neck (sling procedure) in women has proved effective in 80% to 95% of those electing to have this surgical corrective procedure. Outcomes in older women are comparable with those in younger women. Outflow obstruction incontinence secondary to prostatic hypertrophy is generally corrected by prostatectomy. Sphincter dysfunction resulting from nerve damage following surgical trauma or radical perineal procedures is 70% to 90% repairable through sphincter implantation. Periurethral injections of collagen are also used and add bulk to the internal sphincter and close the gap that allowed leakage to occur. This is a short-term alternative and usually requires a series of injections

System Resources

System resources are the informal or formal sources of care available to older adults who live in the community. System resources may include resources such as in-home care services, home health services, or family care.

The biofield

The Biofield All objects radiate a hierarchy of unique electrical, magnetic, and radioactive fields. Living beings are considered complex, open systems, always self-organizing, responding, and adapting to the environment to maintain homeostasis. The biofield-energy field model asserts that an electromagnetic/radiation field around living organisms is involved in homeostasis and the communication of body functions interacting with cellular health, emotions, social connections, the environment, and healing. The heart, for example, is known to give off electrical, magnetic, chemical, and thermal fields as well as signals that are uniquely different from all other body tissues and organs. The brain gives off waves that are measured and so important that they give information for decisions on whether life support should be discontinued. The body gives off numerous other waves, but we do not know how to measure or interpret them.

Health Promotion Model

The Health Promotion Model (HPM) defines health as a positive, dynamic state, not merely the absence of disease. Health promotion increases a patient's level of well-being. The HPM describes the multidimensional nature of people as they interact within their environment to pursue health . The model focuses on the following three areas: (1) individual characteristics and experiences; (2) behavior-specific knowledge and affect; and (3) behavioral outcomes, in which the patient commits to or changes a behavior.

Holistic Health Model

The Holistic Health Model of nursing promotes a patient's optimal level of health by considering the dynamic interactions among the emotional, spiritual, social, cultural, and physical aspects of an individual's wellness ( LaVela et al., 2017 ). You put your patients at the center of their care and recognize your patients as the ultimate experts concerning their own health. A patient's subjective experience is relevant in maintaining health or assisting in healing. The Holistic Health Model empowers patients to engage in their own recovery and assume some responsibility for health maintenance -Attempts to create conditions that promote optimal health

The Shifting Perspectives Model of Chronic Illness

The Shifting Perspectives Model is derived from a synthesis of qualitative research findings of living with chronic illness as an ongoing, continually shifting process in which the person moves between the perspectives of wellness in the foreground or illness in the foreground. This model is more reflective of an "insider" perspective on chronic illness as opposed to the more traditional "outsider" view. At any point in time, one may take precedence over the other, but the goal is to move toward the highest level of well-being even in the presence of illness through appropriate interventions. The focus is on health within illness rather than illness first. People's perspective of the chronic illness is neither right nor wrong but is a reflection of their needs and situation. How people perceive the chronic illness at any given time influences how they interpret and respond to the disease, themselves, caregivers, and situations affected by the illness. -Ongoing and focusing on the emotional, spiritual, and social aspects

A—Activity

The ability to continue to participate in enjoyable activities is an important part of healthy aging. However, activity assessment is exceedingly complex because of the range of abilities among those referred to as "older adults." As more baby boomers join this group, the complexity of assessment increases. It ranges from the risk for falling and the need for, and correct use of, assistive devices to the degree to which one can participate in aerobic exercises. Assessment of activity abilities may be accomplished by the combined efforts of nurses, physical therapists, and personal trainers.

Competence

The ability to understand information that is relevant to the decision being made is part of the internal influence of competence. Determining decision-making capacity is at best an inexact science. Deciding that an older adult lacks decision-making capacity silences the voice of the elderly individual. To achieve autonomy, individuals must have rational capacity, sufficient knowledge about their situation, and no internal (mental or emotional) or external (physical) constraints. At best, determining decision-making capacity is a multi-level and complex construct. Older adults may be able to make decisions in one area of their life but not in another Older adults with mild to moderate cognitive impairment are consistently able to answer questions about choices, preferences, and make decisions about daily living activities.

Abstract

The abstract summarizes the entire study, usually in 100 words or less. Some journals require a particular format that addresses the question, subjects, methods, results, and conclusions in separate sections. The abstract gives a very broad understanding of the content of the entire article.

Impact of Elder Abuse

The abuse of elders has effects that are more far-reaching than is usually discussed. Those subjected to even minimal abuse have been found to have a 300% higher risk for death than those who have never been abused. In addition, older adults who have been victims of violence have more health problems than other older adults, including increased bone or joint problems, digestive problems, depression or anxiety, chronic pain, hypertension, and cardiovascular disease.

Atypical Presentation of Illness

The atypical presentation of illness in older adults means that the presentation itself is vague, altered, or not presented at all. In some cases, the signs of 1 disease might be hidden by the signs of another. Conditions in which atypical presentation is common are infections, falls, urinary incontinence, myocardial infarct, and congestive heart failure. Signs and symptoms of atypical presentation include acute confusion (delirium), inability to eat or drink (anorexia), absence of temperature elevation or fever even with an elevated white blood count (leukocytosis), no complaint of pain with a disease/condition known to cause pain (e.g., gastric ulcer), reduced mobility and overall functional decline, generalized weakness and fatigue, falls, and urinary incontinence.

Validation Therapy

The caregiver accepts values and beliefs of the resident with dementia, even though they may differ from reality

Depression Etiology

The causes of depression in older adults are complex and must be examined in a biopsychosocial framework. Factors of health, gender, developmental needs, socioeconomics, environment, personality, losses, and functional decline are all significant to the development of depression in later life. Depression can occur for the first time in late life or can be part of a long-standing mood disorder with onset in earlier years. Compared with patients with early-life depression, older patients with late-onset major depression have less frequent family history of mood disorders. Biologic causes, such as neurotransmitter imbalances, have a strong association with many depressive disorders in late life. This may be a factor in the high incidence of depression in individuals with neurological conditions such as stroke, Parkinson's disease, and Alzheimer's disease.

Data collection

The characteristics, or variables, collected are described along with how the data were collected. If special equipment was used, it usually is described here. If a survey or questionnaire was used, the author may include sample questions or the entire set of questions. Practices to ensure that data were collected accurately over the course of the study are described. This might include information about training of data collectors, calibration of equipment, and reliability (same results over time) and validity (measure what it is supposed to measure) of questionnaires/surveys or tools/equipment used. The author is demonstrating that the right data werecollected from the right subjects in the right manner. At this point in the review, ask the following questions: 1. Did the researchers choose the ìrightî subjects? 2. Did the researchers choose the ìrightî variables? 3. Do the procedures used in this study make sense? 4. Was the data-collection process logical or was there too much potential for error?

Spiritual Well-Being

The concept of spiritual well-being has multiple dimensions. The common dimensions of spiritual well-being include meaning and purpose, a sense of peace or fulfillment, and connectedness with others and God or a higher power. Those who experience spiritual well-being feel connected to others and are able to find meaning or purpose in their lives. Those who are spiritually healthy experience joy, are able to forgive themselves and others, accept hardship and mortality, and report an enhanced quality of life.

Power and Coercion

The effects of unequal power relations in health-related decision-making is a significant issue. How decisions are framed and by whom has a significant impact on how the information is processed and used by the decision-maker. When health care team members position themselves as expert, and the older adult's or family's opinion fall secondary to the expert opinion, patient input into the discussion may be discouraged and the patient's and family's wishes or desires may not be given full credence or considered pertinent. It may be valuable to encourage the older adults and their families to give input into a discussion about possible care and services rather than to simply agree or disagree with recommendations. Other forms of disempowerment may include viewing patient dissention as refusal instead of voicing an independent decision. Topics that have strong emotional overtones, such as the patient's safety at home, are particularly vulnerable to the influences of expert power.

Nonpharmacological Treatment of Constipation

The first intervention is to examine the medications the person is taking and eliminate those that produce constipation, preferably changing to medications that do not carry that side effect. Medications are the leading cause of constipation, and almost any drug can cause it. Other interventions that have been implemented and evaluated are as follows: (1) fluid and diet related, (2) physical activity, (3) environmental manipulation, (4) toileting regimen, and (5) a combination of these.

Signs of Mistreatment

The first signs that further evaluation may be necessary are if the histories given by the (usually cognitively intact) elder and the caregiver are inconsistent or the caregiver refuses to leave the elder alone with the nurse. Although it is always important to ask the elder if he or she is a recipient of abuse/shame/suffering/family disharmony/moral cruelty, one cannot assume that this will be acknowledged.

Healthy People 2030

The framework proposed by Healthy People 2030 will build on the previous editions of Healthy People, promote a holistic approach to health promotion and disease prevention, and help to engage community leaders to act and design policies to improve the health and well-being of all Americans

Phase 1—Assess the Need

The goal of Phase 1 is to determine an organization's readiness for undertaking a TeamSTEPPS-based initiative. Such practice is typically referred to as a training needs analysis, which is a necessary first step to implementing a teamwork initiative.

Phase 3—Sustainment

The goal of Phase 3 is to sustain and spread improvements in teamwork performance, clinical processes, and outcomes resulting from the TeamSTEPPS initiative. The key objective is to ensure opportunities exist to implement the tools and strategies taught, practice and receive feedback on skills, and provide continual reinforcement of the TeamSTEPPS principles on the unit or within the department

Alcohol Use Disorder: Consequences

The health consequences of long-term alcohol use disorder include cirrhosis of the liver, cancer, immune system disorders, cardiomyopathy, cerebral atrophy, dementia, and delirium. Effects of alcohol on cognitive function are receiving greater attention, and a recent study reported that middle-aged men who drink more than 2.5 standard drinks a day are more likely to experience faster decline in all cognitive areas, especially memory. It is estimated that 10% of dementia is alcohol related. Other effects of alcohol in older people include urinary incontinence, which results from rapid bladder filling and diminished neuromuscular control of the bladder; gait disturbances, from alcohol-induced cerebellar degeneration and peripheral neuropathy; depression; functional decline, increased risk for injury; and sleep disturbances and insomnia. Alcohol misuse has also been implicated as a major factor in morbidity and mortality as a result of trauma, including falls, drownings, fires, motor vehicle crashes, homicide, and suicide. Alcohol use also exacerbates conditions such as osteoporosis, diabetes, hypertension, and ulcers. The rate of hospitalization of older adults for alcohol-related conditions is similar to those admitted for myocardial infarction. Many drugs that elders use for chronic illnesses cause adverse effects when combined with alcohol. All older people should be given precise instructions regarding the interaction of alcohol with their medications.

Providing Care for Activities of Daily Living in Someone with Dementia

The losses associated with dementia interfere with the person's communication patterns and ability to understand and express thoughts and feelings. Perceptual disturbances and misinterpretations of reality contribute to fear and misunderstanding. Often, bathing and the provision of other ADL care, such as dressing, grooming, and toileting, are the cause of much distress for both the person with dementia and the caregiver.

Circle of Control

The model "Circle of Control" was developed through a concept analysis of decision-making (Popejoy, 2001). The Circle of Control has three intersecting circles that represent the the older adult, the older adult's family or support individual, and health care team members. The circles and intersections of the circles may be larger or smaller depending on the amount of decision-making control and desire for involvement preferred by each member represented by circles. The amount of decision-making control is influenced by internal factors, outside resources, and system resources. The intersections of the circles represent shared decision-making responsibility of the older adult, family or support individual, and health care team member (Figure).

Misuse of Drugs

The more drugs taken, the more likely misuse will occur. Forms of drug misuse include overuse, underuse, erratic use, and contraindicated use. Misuse can occur for any number of reasons, from inadequate skills of the nurse or the prescriber to inadequate funds to purchase prescribed medications.

The Aphasias

The most common language disorder associated with neurological impairments is one or more of the aphasias. Aphasia may occur suddenly such as following a stroke or slowly from advancing AD or PD. It may affect a person's ability to speak, to understand speech, and to read, write, or gesture in one or more ways and in varying degrees. Depending on the type and severity of the aphasia, there may be little or no speech, speech that is fragmented or broken, or speech that is fluent but empty in content. When the stroke affects the dominant half of the brain, some disruption will occur in the "word factories," which are specific to the Broca's and Wernicke's areas in the cerebral cortex. The National Aphasia Association categorizes the two major types of aphasia as fluent and nonfluent.

Geriatric Depression Scale

The most commonly used mood measure in both middle-aged and older adults is the Geriatric Depression Scale (GDS), developed by Yesavage and colleagues. The GDS has been extremely successful in determining depression because it deemphasizes physical complaints, sex drive, and appetite—those things most affected by medications. It has been tested extensively with translations in multiple languages. A shortened 15-item version is now used, with the free resources provided by Drs. Yesavage and Brink. The instrument can be completed on an iPhone or ANDROID with an automatic calculation of the results, which can be downloaded to a computer. It cannot be used in persons with dementia or cognitive impairment. Dr. Yesavage may be contacted directly at Stanford University for more information and a description of the products he has available.

Instrumental Activities of Daily Living

The original tool for the assessment of IADLs was developed by Lawton and Brody . Both the original tool and the subsequent variations use the self-report, report-by-proxy, and observed formats with three levels of functioning (independent, assisted, and unable to perform). EX: • Ability to use the telephone • Ability to travel • Ability to shop for necessities • Ability to prepare meals • Ability to do housework • Ability to self-administer medication • Ability to manage money

According to A Patient's Bill of Rights (1998):

The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of the medical consequences of this action. In case of such refusal, the patient is entitled to other appropriate care and services that the hospital provides or transfer to another hospital. The hospital should notify patients of any policy that might affect patient choice within the institution.

Cognitive Impairments and Falls

The presence of neurocognitive disorders, such as dementia and delirium, increases risk for falls twofold, and individuals with dementia are also at increased risk of major injuries (fracture) related to falls. Fall risk assessments may need to include more specific cognitive risk factors, and cognitive assessment measures, especially for delirium, may need to be more frequently scheduled for at-risk individuals •Those with dementia and delirium are at an increased risk for falls and major injuries if falls occur •Screening tools can be used to identify cognitive impairments

Excretion

The process by which metabolic wastes are eliminated from the body -primary organ for excretion is the kidneys

Absorption

The process by which nutrient molecules pass through the wall of the digestive system into the blood -depends on the route (iv fastest and oral the slowest) -depends on gi motility

The Progressively Lowered Stress Threshold Model

The progressively lowered stress threshold (PLST) model was one of the first models used to plan and evaluate care for people with NCDs in every setting. The PLST model categorizes symptoms of NCDs into four groups: (1) cognitive or intellectual losses, (2) affective or personality changes, (3) conative or planning losses that cause a decline in functional abilities, and (4) loss of the stress threshold, causing behaviors such as agitation or catastrophic reactions. Symptoms such as agitation are a result of a progressive loss of the person's ability to cope with demands and stimuli when the person's stress threshold is exceeded.

Chronopharmacology

The relationship between the biological rhythms of the body and variations in pharmacokinetics and pharmacodynamics is referred to as chronopharmacology. For example, if a cortisone tablet (e.g., from a Medrol dose pack) is taken in the morning, it may have little or no effect on the adrenocortical system. If the same dose is taken in divided amounts over the day, unwanted effects of the drug may suppress the hormonal activities stemming from the hypothalamus-pituitary-adrenal axis.

Third Generation Theories

The third generation of theoretical development related to aging is also referred to as the "second transformation" occurring since the 1980s. The goal is "understanding the human meanings of social life in the context of everyday life rather than the explanation of facts". This may or may not rise to the level of a theory. -really look at life stories and understand human meaning

Title

The title indicates the general topic of the study. Most of the time, the title gives a very good idea of what the research study explored.

Trajectory Model of Chronic Illness

The trajectory model, has long aided health care providers to better understand the realities of chronic illness and its effect on individuals. According to this theoretical approach, chronic illness can be viewed from a life course perspective or along a trajectory. In this way, the course of a person's illness can be viewed as an integral part of the person's life rather than as an isolated event. The nurse's response is then holistic rather than isolated. The time between the diagnosis of an illness and death is divided into eight phases for the purpose of identifying goals and developing interventions. The shape and stability of the trajectory are influenced by the combined efforts, attitudes, and beliefs held by the older person, family members, and significant others, and the involved health care providers. Although it appears linear, it is instead fluid as crises reappear and are addressed and as instability becomes stable again until this is no longer possible. -Life course perspective and as an integral part of lives, not as a single event -Eight different phases

Hip Protectors

The use of hip protectors for prevention of hip fractures in high-risk individuals may be considered; there is some evidence that hip protectors have an overall effect on rates of hip fracture, but further research is needed to determine their effectiveness. Compliance has been a concern related to the ease of removing them quickly enough for toileting, but newer designs that are more attractive and practical may assist with compliance issues

Nonsurgical Devices for UI

There are a variety of intravaginal or intraurethral devices to relieve stress UI. These include intravaginal support devices, pessaries, external occlusive devices, and urethral plugs for women. For men, there are foam penile clamps. The pessary, used primarily to prevent uterine prolapse, is a device that is fitted into the vagina and exerts pressure to elevate the urethrovesical junction of the pelvic floor. The patient is taught to insert and remove the pessary, much like inserting and removing a diaphragm used for contraception. The pessary is removed weekly or monthly for cleaning with soap and water and then reinserted. Adverse effects include vaginal infection, low back pain, and vaginal mucosal erosion. Another concern is the danger of forgetting to remove the pessary. An evaluation of the stress UI by the health care provider should be conducted to determine if these devices would be helpful.

Immunological Theory

There are branches and changes that happen directly to the immune system and that aging is a result of the accumulation of damage that occurs to the immune system. There might be a chronic state of inflammation occurring that with damage to the immune system causes aging and death.

Role Expectations

There are many different roles that may be played by older adults, their family member(s), and the health care team in health care decisions. The role chosen by older adults and their family member(s) vary in scope and intensity, are very important to the decision-making process, and tend to be consistent with past decision-making incidents. Davison et al. in study about decision-making preferences in men with cancer found that a majority (58%) preferred a passive treatment decision role, 23% a collaborative role, and 19% an active role. In a study of men with prostate cancer, Clark, Wray, and Ashton found that men who had voiced regrets about their treatment choices were, in general, less satisfied about the role they played in making treatment decisions. Dissatisfaction with the degree of communication about health-related information was often related to an underestimation of patient need for information and involvement.

Risk Factors for Delirium

There are many predisposing and precipitating factors for delirium. The risk of delirium increases with the number of risk factors present. Among the most predictive risk factors are age greater than 65 years, mild or major neurocognitive disorders (NCDs), poor vision or hearing, functional deficits, infection, acute illness, alcohol or drug abuse, laboratory or electrolyte abnormalities, and respiratory insufficiency. Unrelieved or inadequately treated pain significantly increases the risk of delirium. Invasive equipment, such as nasogastric tubes, intravenous (IV) lines, catheters, and restraints, also contributes to delirium by interfering with normal feedback mechanisms of the body. Anticholinergic medications, sedative-hypnotics, and meperidine contribute considerably to delirium risk. The Beers Criteria for potentially inappropriate medication use in older adults is a resource for potential problem medications.

Decision Type

There are many types of decisions that range from everyday decisions to decisions about serious events that have long lasting implications. Major decisions as they relate to health care include making decisions about life and death issues, such as resuscitation, major surgery, or relocation to an institution. Minor decisions, or everyday decisions, relate to the multiple choices that arise daily in life, such as issues about recreation, food, clothing, and organization of daily routines. How stressful a decision is perceived to be may depend on the comfort level associated with making that decision

Medication-Herb/Supplement Interactions

There are multiple herbs that have an effect on coagulability

Dietary Recommendations for older adults: protein

There has been discussion that the Institute of Medicine's Recommended Dietary Allowance (RDA) for protein of 0.8 g/kg per day, based primarily on studies in younger men, may be inadequate for older adults. Protein intake of 1.5 g/kg per day, or 20% to 25% of total calorie intake, may be associated with a decline in risk of frailty in older adults. Older people who are ill are the most likely segment of society to experience protein deficiency. Those with limitations affecting their ability to shop, cook, and consume food are also at risk for protein deficiency and malnutrition.

Later Life Transitions

This chapter examines the various relationships, roles, and transitions that characteristically play a part in later life. The transitions of retirement, widowhood, and widowerhood and the concepts of family structure and function, as well as intimacy and sexuality, are examined. Nursing responses to support older adults in maintaining fulfilling roles and relationships and adapting to transitions are discussed.

Subjects

This section explains the candidates for participation in the study, often stating criteria for inclusion (who can be in) and exclusion (who cannot be in). Where the subjects were found (the setting) and how they were invited to participate in the study also are described.

Magician role:

To understand what the person is trying to communicate both verbally and nonverbally, we must be a magician who can use our magical abilities to see the world through the eyes, the ears, and the feelings of the person. We know how to use tricks to change an individual's behavior or prevent it from occurring and causing distress.

Opioid Analgesics

Treat both acute and persistent physical pain Require utmost caution in their use with older adults -May produce a greater analgesic effect, a higher peak, and a longer duration of effect -Side effects (gait disturbance, dizziness, sedation, falls, nausea, pruritus, and constipation) -Sedation increases risk for falls

T or F: The rate of suicide among older adults in most countries is higher than for any other age group.

True

Criteria for Defining Chronic Functional Constipation in Adults

Two or more of the following for at least 12 weeks in the preceding 12 months: • Straining with defecation more than 25% of the time • Lumpy or hard stools more than 25% of the time • Sensation of incomplete emptying more than 25% of the time • Manual maneuvers used to facilitate emptying in more than 25% of defecations (digital evacuation or support of the pelvic floor) • Fewer than 3 bowel movements per week

Health Care Insurance Plans in Later Life

Until 1965 there were only a few successful insurance plans for wealthier working people. In most cases health care was on a fee-for-service, out-of-pocket basis. This meant that each health care service could only be obtained if delivered by the provider, bartered, or purchased for cash (or "out-of-pocket"). When costs were reasonable, many older adults could continue to pay for their care. However, as people began to live longer with more chronic health problems, advances in technology escalated, and costs for health care increased, paying for health care out-of-pocket became harder and even impossible for many older adults who were entirely dependent on limited incomes.

Incontinence

Urinary incontinence (UI) can occur secondary to age-related physiological changes, iatrogenesis, frailty, or disease. Urinary incontinence is not a normal age-related change or consequence of aging. -4 types of urinary incontinence: urge, stress, overflow, and functional. Fecal incontinence, almost as common as UI, is frequently a result of fecal impaction. Not surprisingly, constipation and fecal impaction are associated with chronic use of laxatives, constipating medications (e.g., opioids, iron, calcium channel blockers), limited mobility, malnutrition, reduced fluid intake, and the 3 Ds: delirium, dementia, depression.

Psychosocial/emotional abuse

Verbal and nonverbal acts that inflict mental pain, anguish, fear, and distress Ex: Insults, threats, humiliation, intimidation, harassment, social isolation, destroying property

Weight Loss

Weight loss is a very common problem in older adults. Weight loss can be caused by the diminished sense of taste that comes with aging, or it can be a suggestion of an underlying serious medical problem. No matter the cause, weight loss can lead to other problems, such as weakness, falls, and bone disorders. -Your healthcare provider should weigh you each time you visit and check for any changes. Also, be sure to let your healthcare provider know if you have any changes in your weight or appetite. (Common And Often Related Medical Conditions In Older Adults)

F—Fluids

What is the current state of hydration? Does the person have the functional capacity to consume adequate fluids to maintain optimal health? This includes the abilities to sense thirst, mechanically obtain the needed fluids, swallow them, and excrete them. Medications are reviewed to identify those with the potential to affect intake. This is especially important when working with older adults who are not able to independently access fluids because of functional limitations, or for anyone with a reduced sense of thirst, a common change with aging.

N—Nutrition

What mechanical and psychological factors affect the person's ability to obtain and benefit from adequate nutrition (see Chapter 10)? What is the type and amount of food consumed? Does the person have the abilities to bite, chew, and swallow? What is the oral health status and what is the impact of periodontal disease if present? For edentulous persons, do their dentures fit properly and are they worn? If a special diet is recommended, has it been designed so that it is consistent with the person's eating and cultural patterns? Can the person afford the special foods needed? Is the person at risk for aspiration? Have preventive strategies been taught or provided, including meticulous oral hygiene?

Report-by-proxy

When assessment information is obtained indirectly (report-by-proxy) the nurse asks another person to report his or her observations. This approach is used extensively with persons who are cognitively impaired; the elder's abilities and health are often underestimated.

Personal Values and Beliefs

Within life context are personal values and beliefs, which serve as a filter for processing information related to decisions and are integral to the decision-making process and outcomes. The values and beliefs of the individual decision-maker are vital, but of equal importance are the normative values and beliefs of the family or support individual. Health-related decision-making is either an individual or a collective process. In modern American society individualistic beliefs are more prevalent than collectivist belief structures. Those with individualistic beliefs value self-reliance, self-responsibility, and control. Those with collectivist beliefs involve others, particularly family members in life events and decisions. Latino and African American cultures are examples of people that may value collectivist beliefs more than individualistic beliefs

Considerations of Common Changes in Late Life During the Physical Assessment: Genitourinary female

Women have nonpalpable ovaries; short, dryer vagina; decreased size of labia and clitoris; sparse pubic hair. NOTE: Use utmost care with exam to avoid trauma to the tissues.

Who is at economic risk?

Women, those with disabilities, who have lacked access to education or held low-paying jobs with no benefits, and those who are not eligible for Social Security

Vulnerability

a collection of individuals who are more likely to develop health problems as a result of excess risks limits and access to health care services are being dependent on others for care

Compassion Fatigue

a state of exhaustion experienced by medical and psychological professionals, as well as caregivers, which leaves the individual feeling stressed, numb, or indifferent

Wandering and Dementia

a syndrome of dementia-related locomotion behavior having a frequent, repetitive, temporally disordered and/or spatially disoriented nature that is manifested in lapping, random and or pacing patterns, some of which is associated with eloping, eloping attempts or getting lost unless accompanied -Risks include visuospatial impairments, anxiety, depression, poor sleep, unmet needs, and a more socially active premorbid lifestyle -one of the most difficult management problems -1/5 with dementia wanders -complex behavior and not well understood.

Braden Scale

accesses risk of pressure ulcers with 6 risk factors sensory perception, moisture, activity, mobility, nutrition, friction and shear

AIDET

acknowledge, introduce, duration, explanation, thank you

What is the nurse's role when caring for an older patient with a chronic illness? a. Implement an individualized therapeutic regimen that brings about a cure. b. Assist the patient to live at the optimal level of health and wellness. c. Explain to the patient that chronic illness is an inevitable consequence of aging. d. Focus on the patient's limitations as care goals and expectations are set.

b. Assist the patient to live at the optimal level of health and wellness.

Pretrajectory phase of chronic illness

before the illness course begins, the preventive phase, no signs of symptoms present

Successful aging

can be defined as the enjoyment of health and vigor of the mind, body, and spirit into middle age and beyond. For many, it is also the freedom from impairment and the ability to live independently. As the population ages and more individuals are enjoying good health into their 80s and beyond, there is an accompanying interest in factors associated with successful aging.

Choose the INCORRECT statement: a. Delirium comes on suddenly. b. Someone with depression will likely have a clear level of consciousness. c. Dementia comes on slowly and often goes unnoticed for years. d. Someone with delirium usually has a normal level of orientation.

d. Someone with delirium usually has a normal level of orientation.

Intermediate Memory

days to weeks

Healthy People 2010

emphasized link between individual and community health -health of community influenced overall health of the nation

cultural proficiency

implement changes to improve services based upon cultural needs, do research and teach

Verbal apraxia or apraxia of speech

is a motor speech disorder that affects the ability to plan and sequence the voluntary muscle movements needed to produce speech. The muscles of speech are not paralyzed; instead there is a disruption in the brain's transmission of signals to the muscles. When thinking about what to say, the person may be unable to speak at all or may struggle to say words. In contrast, the person may be able to say many words or sentences correctly when not thinking about the words. Apraxia frequently occurs with aphasia.

Injury etiology

is defined as the mechanism of injury, specifically the circumstances and forces that caused the injury, such as fall or assault. Examining relationships between specific injuries and etiologies can aid in distinguishing common accidental injuries from intentional injuries by increasing the understanding of injury potential following an event.

Components of cognition

language our thoughts our memories our judgment attention perception how we move our bodies

"The Great Imitator"

many of the symptoms (fatigue, weight loss, lack of appetite) for STD could be attributed to lots of things

reality orientation

method of care used to promote awareness of reality in confused or disoriented patients

Sleep Quality and Aging

older adults tend to spend more time in bed awake before falling asleep -wake up more at night -tend to nap more during the day -early to bed early to rise -tend to have lighter sleep -more likely to have abnormal breathing or leg movements

Pharmacodynamics

refers to the interaction between a drug and the body. The older the person becomes, the more likely there will be an altered or unreliable response of the body to the drug. Although it is not always possible to explain the change in response, several mechanisms are known.

There are three approaches used for collecting assessment data:

self-report, report-by-proxy, and observation.

Intersectionality

the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage.

Cognition

the process of how we get information, store it share it with others, and use it

Chronopharmacy

timing with circadian rhythm -trying to give meds based on best time in the body for the med to move through the body -using timing and circadian rhythm

Indwelling catheter

use is not appropriate for long-term management (more than 30 days) except in certain clinical conditions. Regulatory standards in nursing homes follow these same guidelines, and the use of indwelling catheters must be justified on the basis of medical conditions and failure of other efforts to maintain continence. In hospitals, the use of indwelling catheters is often unjustified, and they are used inappropriately or left in place too long. Between 14% and 25% of patients in the hospital setting will have an indwelling catheter, up to half of which can be inappropriate. Reasons for this include (1) convenience to manage UI; (2) lack of knowledge of risks associated with use and alternative treatments; (3) failure of providers to track continued use; and (4) lack of valid continence assessment tools for older adults.

Mixed or unspecified pain

usually has mixed or unknown causes. A compression fracture causing nerve root irritation, common in older people with osteoporosis, is an example of a mix of nociceptive and neuropathic pain.

What cognitively could change in a normal aging adult?

verbal fluency, logic, selective attention, naming of things, and more complex visuals spatial cues

Immediate Memory

within minutes or seconds

Cardiac Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Chest, shoulder, or jaw pain and circumstances in which pain occurs • If already taking antianginal medication such as nitroglycerin, how often is it needed • Sense of heart palpitations • If using anticoagulants, any evidence of bruising or bleeding

Simplification Strategies (Useful With ADLs)

• Give one-step directions. • Speak slowly. • Allow time for response. • Reduce distractions. • Interact with one person at a time. • Give clues and cues as to what you want the person to do. Use gestures or pantomime to demonstrate what it is you want the person to do—for example, put the chair in front of the person, point to it, pat the seat, and say, "Sit here."

Hypoactive Delirium

• Quiet or "pleasantly confused" • Reduced activity • Lack of facial expression • Passive demeanor • Lethargy • Inactivity • Withdrawn and sluggish state • Limited, slow, and wavering vocalizations generally harder to see; is quieter; more likely to be missed

Late Life Income

•1935 Social Security Act •Social Security •Supplemental security income (SSI) •Private investments •Pensions

Identifying who is at risk for spiritual distress

•Conditions affect rituals •Depression •Confusion •Terminal diagnosis •Loss of support •Questioning faith

Effect of Affordable Care Act

•Expanded access to preventive care •Reduced medication costs •"Welcome to Medicare" exam added during Bush administration; must be done within 12 months of enrolling in Part B (Box. 7.3, p. 82) •ACA added Annual Wellness Visit (Box 7.2, p. 82) •Efforts in Congress to repeal and replace the ACA have not succeeded so far

Pressure Ulcer Risk Assessment

•Frequent •History •Head-to-toe skin examination •Nutritional evaluation •Laboratory findings •Video of skin assessment: https://www.youtube.com/watch?v=L1OpaWDAv_A

TRICARE for Life

•Health care insurance program provided by Department of Defense for eligible beneficiaries •Requires enrollment in both Medicare Part A and Part B and pay premiums for Part B. •As Medigap policy, TFL covers expenses not covered by Medicare such as co-pays and prescription medicines (care for veterans)

Financing Health Care

•In the United States health care has always been a purchased service, not a right •Federal government is the major purchaser of health care via its insurance plans •Medicare •Railroad Medicare •Medicaid •TRICARE •Veterans Administration

Oral Cancer

•More than 60% of oral cancers are not diagnosed until an advanced stage •Early signs and symptoms may be subtle and not recognized by the individual or health care provider •Therapy options include surgery, radiation, and chemotherapy •If detected early, these cancers can almost always be treated successfully

Characteristics of pressure ulcers

•Most often occur on the sacrum, heels, and greater trochanters •Other areas include the lateral condyles of the knees and the ankles, the pinna of the ears, occiput, elbows, and scapulae

Cultural Knowledge

•Orientation to family and self •Orientation to time •Health beliefs

Nurse assessment of sexuality and STDs

◦Ask elders about their sexual satisfaction ◦Screen for HIV/AIDS and other sexually transmitted diseases ◦Perform a medication review ◦Use the PLISSIT model as a guide for sexual discussion

Plawecki & Amrhein article

◦Main points: ◦Patients have the right to refuse treatment. ◦ It must be determined that the elderly patient is capable of understanding the health care information and able to make a decision. ◦Implications for nurses: ◦Nurses may be asked to obtain "informed consent" from patients, and need to understand their accountability and legal liability.

Female sexual dysfunction

◦Mental health ◦Physical changes (post-menopause)

Moral Impacts on Sexuality

-religious, humanistic, pragmatic beliefs

Injury presentation

is defined as the pattern of injury sustained by individuals including the type of injury (e.g., bruise, fracture, abrasion) and body location (e.g., torso, upper arm, head).

Anomia

is the difficulty to retrieve words. This may be in spontaneous speech, such as a conversation or when asked to name a particular object.

Supplemental Insurance

•Nurses can refer clients to Medicare website to search for appropriate plan •Some plans are part of a person's retirement benefit or available to members of organizations such as AARP

External catheters

(condom catheters) are sometimes used in male patients who are incontinent and cannot be toileted. Long-term use of external catheters can lead to fungal skin infections, penile skin maceration, edema, fissures, contact burns from urea, phimosis, UTIs, and septicemia. The catheter should be removed and replaced daily and the penis cleaned, dried, and aired to prevent irritation, maceration, and the development of skin breakdown. If the catheter is not sized appropriately and applied and monitored correctly, strangulation of the penile shaft can occur.

TeamSTEPPS® is a teamwork system designed for health care professionals that is:

-A powerful solution to improving patient safety within your organization. -An evidence-based teamwork system to improve communication and teamwork skills among health care professionals. -A source for ready-to-use materials and a training curriculum to successfully integrate teamwork principles into all areas of your health care system. -Scientifically rooted in more than 20 years of research and lessons from the application of teamwork principles. -Developed by Department of Defense's -Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality.

Vision and Hearing and Falls

-A significant relationship exists between vision and hearing and falls -Risk factors include poor visual acuity, reduced contrast sensitivity, decreased visual field, cataracts, and use of nonmiotic glaucoma medications -Formal vision assessment is an important intervention to identify remediable visual problems

In most legal proceedings claiming that a patient's right to informed consent has been violated, plaintiffs are required to prove four elements if their action is to succeed:

-A specific risk that was not disclosed was involved with the procedure. -The party obtaining consent violated the applicable standard of disclosure. -The undisclosed risk occurred. -The failure of the party to disclose the risk caused injury to the patient.

Insomnia

-Affects sleep quality and quantity -that a person has difficulty falling asleep for at least 1 month and that impairment in daytime functioning results -Risk factor for cognitive decline -most common sleep disorder in the world

Living arrangements of the elderly: Today

-Aging in place: converting the home into something more physically accessible for them -Retirement Communities -"Snow birds": travel from one warm part of the country to another

Considerations of Common Changes in Late Life During the Physical Assessment: Chest

-Any kyphosis will alter the location of the lobes, making careful assessment more important. -Risk for aspiration pneumonia is increased, increasing the importance of the lateral exam and the need for measurement of oxygen saturation. -Evidence of pneumonia may not be evident if the person is dehydrated. -Third heart sound indicative of pathology.

Sleep in Nursing Homes

-As many as 22% to 61% of hospitalized patients experience impaired sleep -Noise, light, physical problems, and staff interactions interfere with sleep -Nurses play critical role

Maslow's Hierarchy of Needs

-Assumes that all people share the basic human needs -Some needs are more basic than others -Most basic needs must be met before higher order needs can be met Nurses use Maslow's hierarchy of needs to understand the interrelationships of basic human needs ( Fig. 6.3 ). Basic human needs are necessary for human survival and health (e.g., food, water, safety, and love). Although each person has unique needs, all people share basic human needs, and the extent to which people meet their basic needs is a major factor in determining their level of health.

Nursing Responsibilities with pain

-Assuring that the patient is comfortable and has the highest possible health-related quality of life -Countering myths, stereotypes, and generalizations about aging and pain

Barriers to pain management

-Attitudes and practices of nurses and other health care providers and from those in pain -Compliance with taking analgesic prescriptions -Underreports of pain -Cost of the medications and fear of side effects -Attributing pain to normal burdens of "old age," belief that nothing can be done, or the fear of addiction -Barriers higher in cultural/racial/ethnic groups that aren't of the highest norm in the setting -Time -Have to assess pain in nursing homes as part of medicare and Medicaid requirements

Possible Reasons for Neglect by Caregivers

-Caregiver personal stress and exhaustion -Multiple role demands -Caregiver incompetence -Unawareness of importance of the neglected care -Financial burden of caregiving limiting resources available -Caregivers' own frailty and advanced age -Unawareness of community resources available for support and respite

Signs of medical abuse

-Caregiver repeatedly requesting procedures that are not recommended and not desired by elder

Aging in place

-Centers for Disease Control and Prevention definition: The ability to live in one's own home and community safely, independently, and comfortably, regardless of age, income, or ability level. -Aging in Place takes planning and preparation -What most people want in their later years -80% of seniors want to stay in their homes as long as possible

Risk factors for dysphagia

-Cerebrovascular accident (CVA, stroke) -Parkinson's disease -Neuromuscular disorders: amyotropic lateral sclerosis (ALS), multiple sclerosis (MS), myasthenia gravis, dystonia -Dementia -Head and Neck cancer -Traumatic Brain injury -Aspiration pneumonia -Inadequate feeding technique -poor dentition

Aging Changes: Eyes and Vision

-Changes are both functional and structural -Change in visual acuity and ability to adapt -Near vision decreases and lens thickens -Dry eyes -Eyelids droop -Color perception decreases (especially to see blue, purple and green) -Sensitivity to glare -Decline in peripheral vision -Intraocular fluid reabsorption down

Early recognition and Diagnostic process: Alzheimers

-Changes noted in comparison to prior state of cognition and memory -Diagnosis- Changes documented with neuropsychological testing; imaging; autopsy

Early recognition and Diagnostic process: Parkinson's

-Changes noted in comparison to prior state of physical stability (tremors, motor signs) -Diagnosis—one of exclusion -Levodopa "challenge" test to see if symptoms improve -If improvement occurs with levodopa, diagnosis is confirmed

Considerations of Common Changes in Late Life During the Physical Assessment: Skin

-Check for indications of solar damage, especially among persons who worked outdoors or live in sunny climates. -Because of thinning of skin, "tenting" cannot be used as a measure of hydration status.

Assessment for Delirium

-Commonly thought of as a hospital-related event, delirium can occur in the ALC, as well. Risk factors include infection, dehydration, fracture, and use of psychotropic medication. The Confusion Assessment Method (CAM) identifies the presence or absence of delirium but not does indicate severity.17 The CAM consists of 4 factors: 1) acute onset or fluctuating course of mental changes or behavior; 2) inattention; 3) disorganized thinking; and 4) altered level of consciousness. Factors 1 and 2 and either 3 or 4 must be present for the diagnosis of delirium.

Nonpharmacologic Treatments for Pain in Older Adults

-Cutaneous nerve stimulation (heat and cold packs watch for risk of burns) -Transcutaneous electrical nerve stimulation -Acupuncture and acupressure- pain is impulses and needles are supposed to interrupt that pain message. -Touch-healing touch, reiki, along with relaxation. Ask for permission -Biofeedback-cognitive behavioral theory that a person can learn to control body and thus pain response. Hard and need full body functioning and dexterity. -Distraction-draw attention to something use. Slow breathing, guided imagery, humor, singing/tapping -Relaxation, meditation, and imagery-relieve tension and anxiety which adds to pain -Pain clinics-multidisciplinary approach-some focus on specific approach to pain. Goal is to decrease pain and improve quality of life.

orthostatic hypotension

-Drop in bp when someone gets up due to a release in vasodilating peptide -Decrease in 20+ systolic; 10+ diastolic with position changes from lying to sitting or sitting to standing -Declines in depth perception, proprioception, and normotensive response to postural changes contribute to falls -Postural changes in the pulse rate and blood pressure occur with postural hypotension -Postprandial hypotension occurs after the consumption of a carbohydrate-filled meal and is more common in those with diabetes or Parkinson's disease

In studies of older adults, resilience was defined as comprising five characteristics:

-Equanimity: a balanced perspective of life. -Meaningfulness: a sense of purpose in life. -Perseverance: the ability to keep going despite setbacks. -Existential aloneness: the recognition of one's unique path and the acceptance of one's life. -Self-reliance: the belief in one's self and capabilities.

Why are falls so important?

-Falls and subsequent injuries result in physical and psychosocial consequences -Leading cause of morbidity and mortality for people older than 65 years of age -A nursing-sensitive quality indicator -Falls in nursing homes are termed sentinel events and must be reported to the Centers for Medicare & Medicaid Services -falls and injuries from falls are the leading cause of unintentional death related to injury for those over 65 -1/3 of all adults fall -important geriatric syndrome -2/3 of falls are preventable

Hospice

-Family centered care that allows patients to live with comfort, independence, and dignity while easing the pains of terminal illness. -Focuses on palliative (not curative) care -Many hospice programs provide respite care, which is important in maintaining the health of the primary caregiver and family. -Hospice care can be provided in the patient's home, an inpatient hospice unit, or a freestanding hospice home. -The interdisciplinary team in the hospice works continuously with a patient's health care provider to develop and maintain a patient-directed individualized plan of care.

Aging Changes: Immunological

-Immunity is reduced with age -Oral temperature is lower -Decreased response to antigens means that white blood cell count will change slower after an infection -Immunoglobulins increase

AD and Communication

-Impaired verbal communication: from neurological disturbances; help people with their ability to receive information, understand what is being said & articulate -Articulation: hampered by mechanical difficulties -Anomia: inability to find words in conversation or name things -Aphasia: can't use or understand spoken or written words from damage to the language site of the brain -Verbal apraxia: when an individual can't move their mouth/tongue to speak

Religion as an external resource

-Importance of religion in one's life: Very important to 65% of people 65 years of age and older (highest of any age group) -Attendance at religious services: Once a week for 48% of people 65 years old and older (highest of any age group)

Restorative Care: Rehab

-Includes physical, occupational, and speech therapy, and social services -Focuses on preventing complications -Maximizes patient function and independence -May be in home, in transitional care or outpatient •Rehabilitation restores a person to the fullest physical, mental, social, vocational, and economic potential possible. •Ideally, rehabilitation begins the moment a patient enters a health care setting for treatment. •Initially, rehabilitation usually focuses on preventing complications related to an illness or injury. •As the condition stabilizes, it helps to maximize a patient's functioning and level of independence.

Pain Interventions

-Is there a reversible cause? -What comfort measures are helpful for this person? -How much activity can they tolerate? -How can risk/benefits be balanced? -Uses a holistic approach because of the complex nature of pain in later life -Determine if there is a reversible cause, such as a uti or a fracture, and address accordingly -Comfort measures include use of pillows for support or body positioning, appropriate and comfortable seating and mattresses, frequent rest periods, and pacing of activities -Encourage the patient to stay as active as possible within his or her comfort range

Critical Thinking: Stress and Coping

-Keep in mind the neurophysiological changes the patient may be experiencing. -Use clear communication principles. -Be confident that you can help the patient manage stress.

Older adults who are not resilient have

-Lack of social supports -Accumulated stressors -Unresolved grief -Preexisting psychiatric illness -Cognitive impairment -Inadequate coping resources

Extrinsic Factors Contributing to Falls

-Lack of support equipment in the bathtub and at the toilet -Height of the bed -Floor conditions -Poor lighting (interior and exterior) -Inappropriate footwear -Improper or inadequate assistive devices -Lack of handrails on stairs (interior and exterior) -Poor design of stairwells -Hazards and obstacles (furniture, cords, throw rugs) that contribute to tripping -Slippery or uneven surfaces -Inappropriate footwear

Aging Changes: Cardiovascular

-Left ventricle wall thickens decreasing the ability of the body to respond to increased circulation and oxygen needs -left atrium size increases -decrease in blood flow -increased risk of heart failure -longer recovery time -vascular system has a decrease in elasticity which decreases blood vessels recoil -stretching of veins

Health Related Decision-Making: Internal Factors

-Life context -Personal values and beliefs -Degree of involvement desired -Role expectations -Competence to understand the issues relevant to the decision -Decisional congruence

Pharmacologic Management of Parkinsons

-Medications focus on replacement, mimicking, or slowing dopamine receptors -First-line medications include carbidopa and levodopa (combo=Sinemet) -Teaching for Sinemet: Take on empty stomach on a set schedule -side effects: hypotension, painful movements, hallucinations, sleep disorders, depression, nausea and vomiting -not a cure; just for symptom management -can wear off in the ability to help treat disease; people will try to avoid taking them as long as possible -sometimes side effects for people are bad and could cause harm

Non-motor signs of parkinsons

-Micrographia - small writing -Facial mask - flat or immobile facial features -Speech and swallowing problems -Orthostatic hypotension -Constipation -Insomnia -Vivid dreams -Impaired cognition -Dementia -Depression

Myth 4: Confusion and Memory Loss Are the Norm

-Mind does slow a bit -Brain neurochemicals change over time -Only up to 20% of people experience serious problems with thinking or memory

Assessments for Dementia

-Mini-COG: consists of a 3-item recall and the Clock Drawing Test; used to Geriatric Nursing, Volume 31, Number 5 371 identify dementia; takes approximately 3-5 minutes to administer. Aspects of cognition tested: recall, registration, and executive function. Unlike the Mini-Mental Status Examination, education level, culture, or language have no effect on the Mini-COG score.15 Older adults who were administered the Mini-COG did not appear stressed or otherwise discomfited by the examination. -Brief Evaluation of Executive Dysfunction: recommended for 4 conditions: 1) when an older adult after hospitalization "seems not quite like his former self"; 2) the Mini-COG fails to reveal the presence of cognitive impairment (i.e., dementia); 3) delirium has been ruled out; and 4) the older adult still has memory/recall and language ability.16 Language and education level can yield false-positive results because a portion of the examination includes word association.16

Changes based on sex: females

-More changes than men -Unable to have babies after ovulation: important physically and emotionally -Breasts are smaller and less firm, more saggy -Ovaries, uterus and cervix atrophy and get smaller -Estrogen levels decrease -Drying of the vagina

Fall Risk Assessment Tools

-Morse Fall Scale •Not for use in long-term care facilities -Performance-Oriented Mobility Assessment -Hendrich II Fall Risk Model •Validated with skilled nursing and rehabilitation centers -Minimum Data Set (MDS) 3.0 •Includes information about the history of falls and hip fractures, as well as an assessment of balance during transitions and walking

Parkinson's and Alzheimer's diseases : Overview

-Most common neurogenerative disorders -Both are terminal conditions characterized by a progressive decline in function -Signs are usually slow to appear -Diagnostic process begins with ruling other conditions out

Elder mistreatment

-Most unrecognized and underreported social problems today -can include infliction of actual harm, a risk for harm to vulnerable older people through the action or behavior of others -it occurs irregardless of educational racial cultural religious socioeconomic background -it can occur in any and all family configurations and in every setting. elder abuse has far reaching effects -older adults who have been victims of violence have more health problems than other older adults

Considerations of Common Changes in Late Life During the Physical Assessment: Blood pressure

-Positional blood pressure readings should be obtained because of the high occurrence of orthostatic hypotension. -Both arms should be checked (at heart level) and the arm with the highest measurement should be recorded. Isolated systolic hypertension is common.

foot deformities

-Nurse must assess the feet for clues of functional ability and identify problems -Deformities and ill-fitting footwear can cause gait problems -Contributing factors include neglect of corns, bunions, overgrown toenails, loss of fat cushioning, poor arch support, excess weight-bearing activities, obesity, or uneven distribution of weight on the feet -care of the feet is an important part of mobility but often gets neglected -people with diabetes especially have trouble with feet because of neuropathy

Implications for Gerontological Nursing and Healthy Aging: RETIREMENT

-Nurses may work with people in different phases of retirement -Participate in retirement education and counseling programs -Provide anticipatory guidance about transition to retirement -Identify those who may be at risk for lowered income and health concerns -Refer to appropriate resources -Advocate for policies and conditions that allow older people to maintain quality of life in retirement

The Six Dimensions of Wellness and Cognition in Aging Adults

-Occupational Wellness -Social Wellness -Intellectual Wellness -Physical Wellness -Emotional Wellness -Spiritual Wellness

Behavior Concerns: Dementia

-Occur in all types of dementia -Include anxiety, depression, hallucinations, delusions, aggression, screaming, sleep disturbances, restlessness, agitation, and resistance to care -May be a consequence of multiple, but sometimes modifiable, interacting factors -Should be viewed as a form of communication that is meaningful

Common Aging Myths

-Older adults are disabled, ill, dependent and unattractive -Older adults are forgetful, confused, rigid, and unable to learn new info **Not true of all older adults -Knowledge of the elderly is outdated and of no value *Worth = productivity, and most of the elderly have left the work force

Myth 5: You'll Become Lonely and Depressed

-Older adults are no more likely than younger people to be depressed -Depression in older adults often stems from a loss associated with growing older

PLISSIT Assessment of Sexuality

-Permission to discuss sexuality issues -Limited Information related to sexual health problems being experienced -Specific Suggestions—only when the nurse is clear about the problem -Intensive Therapy—referral to professional with advanced training if necessary

Considerations of Common Changes in Late Life During the Physical Assessment: Vision

-Person exhibits increased glare sensitivity, decreased contrast sensitivity, and need for more light to see and read. -Ensure that waiting rooms, hallways, and exam rooms are adequately lit. Decreased color discrimination may affect ability to self-administer medications safely.

TeamSTEPPS provides higher quality, safer patient care by:

-Producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients. -Increasing team awareness and clarifying team roles and responsibilities. -Resolving conflicts and improving information sharing. -Eliminating barriers to quality and safety.

Adult Day Care Centers

-Provide a variety of health and social services to specific patient populations who live alone or with family in the community -May be associated with a hospital or nursing home or may operate independently -Services offered during the day allow family members to maintain their lifestyles and employment and still provide home care to their relatives -Usually 5 days a week, daily charge -May delay older person's admission to a nursing center

Malnutrition

-Recognized geriatric syndrome -Rising incidence in all settings -Has serious consequences, including infections, pressure ulcers, anemia, hypotension, impaired cognition, hip fractures, prolonged hospital stays, institutionalization, and increased morbidity and mortality -One occurs when the person does not consume sufficient micronutrients and macronutrients to maintain organ function and healthy tissue -Inflammation-related malnutrition develops as a consequence of injury, surgery, or disease that triggers inflammatory mediators that increase metabolic rate and impair nutrient use

Why be active?

-Reduced risk of disease -Reduced risk of falls -Better sleep -Better bone health -Increased life expectancy -Improved function

Intrinsic Factors Contributing to Falls

-Reduced vision and hearing -Problems with balance and gait -Cognitive impairment -Acute and chronic illnesses -Effects of medication (sedatives, hypnotics, anticonvulsants, opioids) -History of a previous fall -Fear of falling -Muscle weakness -Postural hypotension - -Chronic conditions, including arthritis, stroke, incontinence, diabetes, Parkinson's disease, dementia

Elders and adult children

-Relationships between older adults and their children may become strained as a result of -Children of older adults are preoccupied with their own spouses, children, and partners -Elder parents being critical or judgmental about the lives of their offspring -Some older adults are fortunate to see their own children on a regular basis -Nurse may offer tips when family is adding an older person to the household (Box 26.4 in Touhy & Jett)

Is resiliency protective despite life circumstances?

-Resilience has been associated with better health in prior studies. -Successful aging can be defined as the enjoyment of health and vigor of the mind, body, and spirit into middle age and beyond. -Individuals with lower incomes may be less likely to achieve successful aging because of a higher prevalence of health risk factors. -Resilience appears to be positively and significantly associated with indicators of successful aging regardless of income.

Respite Care

-Respite care provides short-term relief or "time off" for people providing home care to an individual who is ill, disabled, or frail. -Settings include home, day care, or health care institution with overnight care. -Trained volunteers enable family caregivers to leave the home for errands or social time. •The family caregiver usually not only has the responsibility for providing care to a loved one but often has to maintain a full-time job, raise a family, and manage the routines of daily living. •There are few formal respite care programs in the United States because of cost. •Currently, Medicare does not cover respite care, and Medicaid has strict requirements for services and eligibility.

Retirement Planning

-Retirement generally has positive effects on life satisfaction and health, although this varies depending on one's circumstances -Finances -Health -Family relationships -The decision to retire is based on finances; attitudes toward work, family roles, and responsibilities; the job; access to health insurance; age; health; and perceptions of ability to adjust to retirement

Assessment of sleep

-Review of sleep patterns -Medication review -Information from sleep partner -Self-rating scales -Sleep study or polysomnogram -Review of sleep patterns -Presence of contributing factors -Sleep diaries or logs -Self-rating scales -Pittsburgh Sleep Quality Index -Epworth Sleepiness Scale -Polysomnography

Spiritual nursing interventions

-See Box 4.4 -Relieve physical discomfort -Authentic presence -Listen -Validate -Encourage family visits -Foster connection -Respect traditions

Alzheimer's disease: Pathophysiology

-Senile plaques & neurofibrillary tangles occur in hippocampus and cerebral cortex -Neurons degenerate which causes acetylcholine production and that effects the information transfer by neurons -Brain cells die -Initial damage is where memories are stored (memories go first)

Factors Influencing Stress and Coping

-Situational factors: Arise from job changes, illness, caregiver stress -Maturational factors: Vary with life stages -Sociocultural factors: Environmental, social, and cultural stressors perceived by children, adolescents, and adults

Alzheimer's Disease

-Sixth leading cause of death in the United States -Not a normal part of aging -Signs include memory loss, impaired thinking, the ability to find words, judgment, and behavior -Cause unknown

Sleep Cycle

-Sleep has five stages -Biorhythms vary -With aging, the natural circadian rhythm may become less responsive to external stimuli

Pain

-Subjective sensation of physical, psychological, or spiritual distress -Multidimensional phenomenon -One type of pain is usually intertwined with another -Pain has many consequences, including questioning the meaning of one's life

Elimination

-The body must remove waste products of metabolism to sustain healthy function -Bowel and bladder functions later in life contribute to the independence of older adults -Nurses are in a key position to implement evidence-based assessment and interventions to enhance continence and improve function, independence, and quality of life for older people

AD Implications for Gerontological Nursing and Healthy Aging

-Treatment focuses on -Making sure the person gets good care -Preserving self-care abilities -Preventing complications and injury -Providing support and guidance in dealing with progressive loss -Promptly treat all reversible conditions -Coordinating care

Health Related Decision-Making: External Factors

-Type of decision -Power relationships -Perception of risk and safety -Options available

Signs of physical abuse

-Unexplained bruising or lacerations in unusual areas in various stages of healing -Fractures inconsistent with functional ability

Signs of Medical Neglect

-Unusual delay between the beginning of a health problem and when help is sought -Repeated missed appointments without reasonable explanations

Nursing interventions:

-Use therapeutic communication skills -Help the person identify his/her own strengths and coping skills -Reinforce use of strengths and coping skills during times of stress, illness, and loss -Help identify and strengthen spirituality and cultural strengths/beliefs -Explore widening options available to older adult in terms of spirituality practices and holistic interventions

Neuman systems model:

-Uses systems approach -Based on the concepts of stress and reaction to stress -stressor in one part of the system (patient, family or community) will effect other parts of the system -multifactorial

Spiritual Implications for Gerontological Nursing and Healthy Aging

-Using evidence-based guidelines for promoting spirituality provides a framework for spiritual assessment and interventions •Older adults want nurses to address spiritual needs •Spiritual assessments include FICA (Faith, Importance or Influence, Community, and Address) and the Brief Assessment of Spiritual Resources and Concerns -The Joint Commission requires spiritual assessments in hospitals, nursing homes, and any care setting for older adults

Adjuvant Medications

-Usually used with an analgesic but may be used alone -Most effective for neuropathic pain syndromes, such as postherpetic neuralgia and diabetic nephropathy -Topical agents (e.g., capsaicin, lidocaine patch) may have mild to moderate local effects

Healthy People 2020

-approved in December 2010 -it promotes a society in which all people live long, healthy lives. -Healthy People 2020 identifies leading health indicators (LHIs) (e.g., access to health services; injury and violence prevention; maternal, infant, and child health), which are high-priority health issues in the United States. Although the United States has made great progress on the LHIs, it falls behind other developed countries on key measures of health and well-being, including life expectancy, infant mortality, and obesity. -health access for all

LGBTQI Individuals

-at especially high risk for discrimination as a result of having been marginalized or oppressed -1973: when homosexuality was removed as a mental health disorder -double stigma: being old and homosexual or having different gender identity -less likely to access health and social services or identify self as LGBTQI to providers -important to be asking questions, supportive and understanding -do not make assumptions -transgender older adults have hardest time with access to healthcare -more likely to have financial issues

Changes based on sex: males

-can still produce sperm, sperm motility changes -testes shrink -ejaculation is slower -testosterone level reduces -prostatic enlargement is common and can lead to urinary retention in some

Basic Processes of the Capacity Examination

-careful review of the patient's medical, surgical, and psychosocial histories -fully understand the situation that requires the capacity examination -interview the patient to determine mental status and assess any potential disturbances such as hallucinations -evaluation of the ability to communicate in some way -explain the purpose of the assessment to the patient and gauge the patient's understanding

Social Impacts on Sexuality

-culture -interpersonal -tv and radio -literature -family -school -teaching

Continuing Care

-describes a variety of health, personal, and social services provided over a prolonged period. -For people who are disabled, functionally dependent, or suffering a terminal disease -Available within institutional settings or in the home (nursing homes, ax living, ind living facility, respite care, adult day care centers, hospice) -The need for continuing care is increasing because people are living longer. -Many of these people do not have family or others to care for them.

Internal Variables Influencing Health and Health Beliefs and Practices

-developmental stage -intellectual background -perception of functioning -emotional factors -spiritual factors

Factors influencing sleep

-drugs and substances -lifestyle -usual sleep patterns -emotional stress -environment -exercise and fatigue -food and caloric intake

Constipation Interventions

-examine meds for constipation-producing effects -increase fluid and fiber intake -promote exercise (walks after meals) -environmental manipulation -establish regularity of bowel evacuation -cautiously use laxatives -use enemas

Skin of Older Adults

-exposures: different exposure to heat/cold, trauma, friction and pressure - effects skin integrity. -uv radiation, tobacco smoke, inflammation in the body can contribute to age related changes -those who are immobilized or fragile are at risk for fungal infections and pressure ulcers

Who is most likely to abuse?

-family member -history of violence -substance abuse -isolated -poor impulse control -mental illness -personal stress/exhaustion

External Variables Influencing Health and Health Beliefs and Practices

-family role and practices -social determinants of health -socioeconomic factors -cultural background

Legal Issues in Gerontological Nursing

-financial issues -health care decisions -consent to treatments -capacity

Aging Changes: Endocrine

-glands shrink -secretion rate decreases -increased insulin resistance

3 questions often asked in assessing falls

-have you fallen this year? -do they look like they will fall? -do they have risk factors for falls? (nurse asks themself)

Tips for drug interactions

-if medications have the same effect, can be harmful, can build on each other -our job as nurses to bring things to physicians if we notice things that shouldn't be given together or are not right

Pain and culture

-important to remember that just because someone is part of a cultural group means they will act -Stoic- grin and bear it, minimize pain- northern Europe/Asian -Emotive-wants to validate pain, cries out-Hispanic, middle eastern, Mediterranean

Reducing Related Risks and Injuries from Osteoporosis

-increasing weight bearing and muscle building activities -improving nutrition in diet (calcium and vitamin d) -getting sunlight (vit d) -stopping smoking -fall prevention -home safety and improvements -looking at meds and managing them

Sleep disorders

-insomnia -sleep apnea -restless leg syndrome -REM sleep behavior disorder -circadian rhythm sleep disorder

Components of a nutritional assessment

-interview -history -physical exam -anthropometric data -labrotory data -food and nutrient intake -functional assessment

Aging Changes: Renal

-kidney blood flow decreases -size and function of the kidney decreases -increased susceptibility to both fluid and electrolyte imbalance -urine creatinine clearance decreases (kidney not getting rid of toxins the same as used to)

Education on Sun Exposure

-less than half of older adults protect their skin from the sun when outside for an hour or more on a warm sunny day - can increase risk of skin cancer -each year in US more than 5 million people are treated for skin cancer - most people over age 65 -little attention to decrease skin cancer risk in this age group -they are living longer, we need to encourage them to protect their skin -shade, wide brimmed hats, sunscreen

Where older adults want to live and where they live

-most want to age in place

Diet for older adults

-needs to have higher protein -more fiber -more fluid -less calories -more b12

pain in older adults with cognitive impairments

-often untreated -assume pain -watch behavior -Pain is consistently untreated and undertreated in older adults with cognitive impairments -Assume any condition that is painful to a cognitively intact person is painful to a person who cannot express him- or herself -Those who can no longer speak for themselves communicate pain through behaviors such as agitation, aggression, increased confusion, or passivity -Really watch for passivity bc may be ignored bc it's easy to care for *CNAs important role in assessment of pain

Risks of Sleep Apnea

-older -male -changes to anatomy of neck -family history -excess weight -substance use -hypertension

Indications for Indwelling Catheter Use

-presence of acute urinary retention or bladder outlet obstruction -need for accurate measurements of urinary output in critically ill patients -perioperative use for selected surgical procedures: urological or other surgery on contiguous structures of the genitourinary tract; anticipated prolonged surgery duration (should be removed in post-anesthesia unit); patients anticipated to receive large-volume infusions or diuretics during surgery; need for intraoperative monitoring of urinary output -assistance in healing of open sacral or perineal wounds in incontinent patients -requirement for prolonged patient immobilization -improvement in comfort for end-of-life care if needed

Suicide in Older Adults

-rates are higher in older adults than any other age -suicide rate for white males 85+ is the highest of all -older widowers are thought to be the most vulnerable -women in all countries have much lower suicide rates -depression and other mental health problems, including anxiety, contribute significantly to suicide risk. -common precipitants of suicide include physical or mental illness, death of a spouse or partner, substance abuse, and chronic pain. -one of the major differences in suicidal behavior in the old and the young is the lethality of method. -8/10 suicides for men 65+ were with firearms. Older people rarely threaten to commit suicide; they just do it.

Healthy people 2020 Goals: Falls

-reduce the rate of ER visits due to falls among older adults -reduce fatal and nonfatal injuries -reduce hospitalizations for nonfatal injuries -reduce ER visits for nonfatal injuries -reduce fatal and nonfatal traumatic brain injuries

Effects of Lack of Sleep

-restricting sleep to 4 hours a night results in higher blood pressures and reduced function of the entire cardiovascular system. -Inflammatory markers increase in the blood, amplifying any chronic pain or inflammatory diseases. -Cells begin showing insulin-resistant behaviors that are known to lead to diabetes. -Appetite increases and activity decreases, predisposing the individual to obesity. -Those who are sleep deprived develop less immunity from vaccines, implying impaired immune function. -Sleep deprivation increases symptoms of mental health disorders and decreases perceived coping ability. -Inadequate sleep is strongly linked to an increased risk of dying. -sleep deprivation has been shown to be associated with increased responsiveness to stress and sensitivity to stress-related disorders.

three dimensional model for assessing capacity:

-risk of the proposed treatment (high versus low) -the benefits of the treatment (high versus low) -the patient's decision regarding the treatment (accept versus refuse).

Biological Impacts on Sexuality

-sexual stimulation -puberty -reproduction -growth and development

Older Adults Falls Statistics

-the death rate from falls is 40% higher for men than women -falls that have fractures related to them are 2x more common in women than men -after a fall there is a 25% increase chance that that person will be in a nursing home within a year -More than 95% of hip fractures among older adults are caused by falls. White women have significantly higher hip fracture rates than black women. -Up to 25% of adults who lived independently before their hip fracture have to stay in a nursing home for at least 1 year after their injury. -The direct medical costs of fall injuries are $31 billion annually. Hospital costs account for two-thirds of the total costs.

A Patient's Bill of Rights: Informed Consent

-the patient has the right to be informed about the kind of treatment or care suggested -alternatives of the suggested care must be discussed with the patient before informed consent can be secured -the patient's voluntary and competent assent to that treatment must be obtained

Risk Factors for oral cancer

-tobacco use, -alcohol use -sun exposure -Oncogenic viruses (especially human papillomavirus) -Genetic susceptibility

Aging Changes: Respiratory

-usually a result of exposure to environmental toxins and not just from the aging process -loss of recoil -stiffening of chest wall -gas exchanges are not as efficient -resistance to air flow increases -cough response and cilia are not as effective -increased risk for aspiration

Keypoints of Carroll article

1 Capacity is a measure of an individual's ability to make an informed and logical decision about a particular aspect of his or her health care. 2 The medical concept of capacity differs from the legal concept of competency, in that capacity is reserved for determination of person's ability to make a single decision and competency encompasses a global determination of one's ability to manage one's own affairs. 3 The threshold for capacity varies with the significance and risk of the decision being made. 4 A capacity examination requires a thorough review of the patient's medical and psychosocial history, as well as the use of a structured interview to determine the patient's understanding of the facts of the issue, mental status, and ability to make a logical decision.

Factors Affecting the Responsibility of Nurses in Obtaining Informed Consent

1. Impaired sensory functioning 2. Low educational level 3. Low or limited health literacy 4. Low literacy of any kind 5. Questionable cognitive status 6. Complexity of procedure (e.g., surgery of any kind) 7. Participation in research

Example tips on reading nursing research

1. Start by identifying the conclusion: -Title -Abstract -Discussion 2.Read the whole article 3.Decide what it means to you

Patterns of Adjustment to Widowhood Stage

1: Reactionary (First Few Weeks) -Early responses of disbelief, anger, indecision, detachment, and inability to communicate in a logical, sustained manner are common. Searching for the mate, visions, hallucinations, and depersonalization may be experienced. -Intervention: Support, validate, be available, listen to individual talk about mate, reduce expectations. Stage 2: Withdrawal (First Few Months) -Depression, apathy, physiological vulnerability; movement and cognition are slowed; insomnia, unpredictable waves of grief, sighing, and anorexia occur. -Intervention: Protect individual against suicide, monitor health status, and involve in support groups. Stage 3: Recuperation (Second 6 Months) -Periods of depression are interspersed with characteristic capability. Feelings of personal control begin to return. -Intervention: Support accustomed lifestyle patterns that sustain and assist individual to explore new possibilities. Stage 4: Exploration (Second Year) -Individual begins new ventures, testing suitability of new roles; anniversaries, holidays, birthdays, and date of death may be especially difficult. -Intervention: Prepare individual for unexpected reactions during anniversaries. Encourage and support new trial roles. Stage 5: Integration (Fifth Year) -Individual will feel fully integrated into new and satisfying roles if grief has been resolved in a healthy manner. -Intervention: Assist individual to recognize and share own pattern of growth through the trauma of loss.

The three common conditions affecting cognition are

3 ds: delirium, dementia , and depression. Distinguishing among these three conditions is challenging. A careful and thorough assessment of older adults with cognitive changes to distinguish among them should be completed. Select appropriate nursing interventions that are specific to the cause of the cognitive impairment. -All frequently affect older adults -Not normal consequences of aging

Assessment of Activity

Assess -Function and mobility -Determine if adaptations are necessary Interventions -Counseling -Initiate a program -Educate -Provide suggestions

Maslow's Hierarchy of Needs

According to this model, certain human needs are more basic than others, and some needs must be met before other needs (e.g., fulfilling physiological needs before the needs of love and belonging). -Used to understand the interrelationships of basic human needs

Activities of Daily Living

Activities of daily living (ADLs) were first classified by Sidney Katz and colleagues in 1963. The Katz Index has served as a basic framework for most of the subsequent measures. On the Katz Index, the ADLs are considered only in dichotomous terms: the ability to complete the task independently (1 point) or the complete inability to do so (0 points). Over the years this instrument has been refined to afford more sensitivity to the nuances of, and changes in, functional status. Despite these limitations, the tool is useful because it creates a common language about patient function for all caregivers involved in planning overall care. ex: Bathing, dressing, eating, and getting around the house

Guidelines for Skin Assessment

Acute care: On admission, reassess at least every 24 hours or sooner if patient's condition changes Long-term care: On admission, weekly for 4 weeks, then quarterly and whenever resident's condition changes Home care: On admission and at every nurse visit

Osteoporosis Pharmacologic Therapies

Adequate intake of calcium and vitamin D ◦A balanced diet (best) ◦Supplements ◦Women 50+ and men 70+: 1200 mg of calcium/day Medications ◦Increase bone mass, reduce bone turnover, or both ◦Come in oral and injectable form ◦Are taken from daily (oral) to yearly (injectable)

Cultural Competence

An understanding of how a patient's cultural background shapes his beliefs, values, and expectations for therapy. -implement changes to improve services based upon cultural needs, do research and teach

Degree of Involvement Desired

Another internal factor is degree of involvement desired by those making the decision. Not all decision-makers desire the same degree or extent of involvement in the decision-making process. -Active -Passive -Collaborative -Avoiding information. Those who preferred a more passive role in health-related decision-making were sicker, less educated, from a minority ethnic groups, male, and elderly. The degree of involvement desired was also influenced by the relationship of the decision-maker to the family or support individual. Degree of involvement, which otherwise may be referred to as degree of participation, may be impacted by beliefs about role expectations of different family members and the health care team, the nature of the decision, the severity of illness, and prior experiences. The degree of involvement desired may influence the role expectations of those involved in the health care decision.

Diagnosis of Parkinson's Disease

Approximately 1 million people have Parkinson's disease (PD) in the United States and 7 to 10 million people worldwide. Ninety-six percent of these persons are diagnosed after the age of 60 and more often in men than in women. PD is the second most common neurodegenerative disease after Alzheimer's disease. The median time between diagnosis and death is 9 years. In very late stages the person may also develop a form of dementia, especially those who develop the disease after the age of 70

The Assessment Process

At a minimum, health assessment includes the collection of physical data and the integration of spiritual and psychosocial factors within an individual's cultural context. When working with older adults, additional assessment areas further include functional and cognitive status, caregiver stress or burden, patterns of health and health care, advance care planning, and the presence or absence of any of the geriatric syndromes (e.g., delirium, falls, dizziness, syncope, and urinary incontinence [see Chapter 17]). Areas or problems frequently not addressed by the care provider or mentioned by the elder that should be addressed are sexual function, depression, alcoholism, hearing loss, oral health, and environmental safety. Although not usually conducted by a nurse, a driving assessment may be recommended any time there is a question of ability. Questions regarding genetic background in this age group, especially for those in the younger range, have most relevance as they relate to Alzheimer's disease, stroke, diabetes, and several types of cancer. Conducting an assessment begins with establishing rapport. It is never appropriate to address the patient by the first name unless invited to do so. The assumption of familiarity of any kind including the use of the first name in addressing an elder can easily be perceived as condescending, especially when the nurse is younger than the patient or of a different ethnic background

Skin Changes at Life's End

•Occur in the last days or weeks of life •Considered unavoidable •Presents as a red, yellow, or purple lesion shaped like a pear, butterfly, or horseshoe on the coccyx or sacrum; the lesion will darken deeply and progress to a full-thickness ulcer in a few days

A—Aeration

Because of the close relationship between pulmonary function (aeration) and cardiovascular function, they are assessed simultaneously. Is the person's oxygen exchange adequate for full respiratory functioning? Measurement of the oxygen saturation rate is a part of this exam and easily done in any setting with a small, inexpensive fingertip device, familiar to most nurses. Persons with any amount of peripheral cyanosis will have artificially low readings. Is supplemental oxygen required and, if so, is the person able to obtain it? What is the respiratory rate and depth at rest and during activity, talking, walking, and exercising and while performing activities of daily living? What sounds are auscultated, what is learned from palpation and percussion, and what do they suggest? For the older person, it is particularly important to carefully assess lateral and apical lung fields.

Acute Illness

Before chronic disorders can be discussed, their relationship to acute illness must be addressed. They cannot really be separated in the health of older adults because so many conditions are intricately intertwined. A previously stable chronic condition condition can and often does worsen when an acute illness occurs. An episode of pneumonia may trigger acute congestive heart failure even though before the episode the failure had been present but controlled through diet and medications.

Bowel Elimination

Bowel function of the older adult, although normally only slightly altered by the physiological changes of age, can be a source of concern and a potentially serious problem, especially for the older person who is functionally impaired. Normal elimination should be an easy passage of feces, without undue straining or a feeling of incomplete evacuation or defecation.

Carpenter role:

By having a wide variety of tools and selecting the right tools for the job, we build individualized plans of care for each person.

Alternative Treatments for Constipation

Combinations of natural fiber, fruit juices, and natural laxative mixtures are often recommended in clinical practice, and some studies have found an increase in bowel frequency and a decrease in laxative use when these mixtures are used. Although research is still limited, many modalities of complementary and alternative medicine, such as probiotic bacteria, traditional herbal medicines, biofeedback, and massage, are also used to treat constipation. Further study is needed but probiotic bacteria might be easiest to use, and supermarkets in several countries carry brands of yogurt labeled probiotic

Mnemonic for Pressure Injury Treatment: DIPAMOPI

Debride Identify and treat infection Pack dead space lightly Absorb excess exudate Maintain moist wound surface Open or excise closed wound edges Protect healing wound from infection/trauma Insulate to maintain normal temperature

Life Context

Decisions are generally believed to be congruous with individuals' views of themselves and are personalized through an individual's life context including past and present viewpoints, events, and relationships. In Gilligan's classic work about women's moral development, the interpretation of events and construction of reality are based on life context. Throughout their lives, individuals experience countless events. How individuals view these events and make decisions about them is based on individual life experiences and socioeconomic, personal, and cultural characteristics.

Consequences of Delirium

Delirium has serious consequences and is a "high priority nursing challenge for all nurses who care for older adults". Delirium is a terrifying experience for the individual and his or her family, and significant others and people often think the patient is "going crazy." Delirium is associated with increased length of hospital stay and hospital readmissions, need for increased services after discharge, and increased morbidity, mortality, and institutionalization, independent of age, coexisting illnesses, or illness severity.

Recognition of Delirium

Delirium is a medical emergency and one of the most significant geriatric syndromes. However, it is often not recognized by health care practitioners. A comprehensive review of the literature suggested that "nurses are missing key symptoms of delirium and appear to be doing superficial mental status assessments". Factors contributing to the lack of recognition of delirium among health care professionals include inadequate education about delirium, limited use of formal assessment methods, a view that delirium is not as essential to the patient's well-being in light of more serious medical problems, and ageist attitudes

Incidence and Prevalence of Delirium

Delirium is a prevalent and serious disorder that occurs in older adults across the continuum of care. Among medical inpatients, inpatients, delirium is present on admission to the hospital in 10% to 31% of older patients. During hospitalization, 11% to 42% of older adults develop delirium. The highest incidence rates have been in intensive care units and in postoperative and palliative care areas. Up to 80% of patients in the intensive care unit (ICU) develop delirium and 5% to 50% of older patients develop delirium after an operation.

What Causes Delirium?

Delirium results from interaction of predisposing factors: -Cognitive impairment -Severe illness -Sensory impairment -Medications -Procedures -Restraints -Iatrogenic events -Dementia -Electrolytes -Lungs, liver, heart, kidney, brain -Infection -Rx (polypharmacy, psychotropics) -Injury, pain, stress -Unfamiliar environment -Metabolic *There is usually more than one cause *It's often reversible!

Delirium

Delirium, or acute confusional state, is a potentially reversible cognitive impairment that occurs suddenly and worsens at night. Delirium often has a physiological cause. Physiological causes include electrolyte imbalances, untreated pain, infection, cerebral anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or hemorrhage. A new onset of delirium should trigger the nurse to assess for signs and symptoms of infections such as pneumonia and UTI. Delirium may also be caused by environmental factors such as sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional distress. Although it occurs in any setting, an older adult in the acute care setting is especially at risk because of predisposing factors (physiological, psychosocial, and environmental) in combination with underlying medical conditions. Between 11% and 42% of hospitalized older adults develop delirium. Dementia is an additional risk factor that greatly increases the risk for delirium; it is possible for delirium and dementia to occur at the same time. The presence of delirium is a medical emergency and requires prompt assessment and intervention. Nurses are at the bedside 24/7 and in a position to recognize delirium development and report it. The cognitive impairment usually reverses once health care providers identify and treat the cause of delirium.

Dementia

Dementia is a generalized impairment of intellectual functioning that interferes with social and occupational functioning. It is an umbrella term that includes Alzheimer's disease (most common type), Lewy body disease, frontal-temporal dementia, and vascular dementia. Cognitive function deterioration leads to a decline in the ability to perform basic ADLs and IADLs. Unlike delirium, dementia is characterized by a gradual, progressive, and irreversible decline in cerebral function. Because of the similarity between delirium and dementia, you need to assess carefully to rule out the presence of delirium whenever you suspect dementia.

Dementia

Dementia is a generalized impairment of intellectual functioning that interferes with social and occupational functioning. It is an umbrella term that includes Alzheimer's disease (most common type), Lewy body disease, frontal-temporal dementia, and vascular dementia. Cognitive function deterioration leads to a decline in the ability to perform basic ADLs and IADLs. Unlike delirium, dementia is characterized by a gradual, progressive, and irreversible decline in cerebral function. Because of the similarity between delirium and dementia, you need to assess carefully to rule out the presence of delirium whenever you suspect dementia. Nursing management of older adults with any form of dementia always considers the safety and physical and psychosocial needs of the older adult and the family. These needs change as the progressive nature of dementia leads to increased cognitive deterioration. To meet the needs of older adults, individualize nursing care to enhance quality of life and maximize functional performance by improving cognition, mood, and behavior. Persons with dementia may exhibit behaviors that may be unsafe, putting them at risk for falls and other injuries. These behaviors are an expression of an unmet need, such as hunger, pain, anxiety, or the need to void or defecate. Therefore, the nurse should consider the meaning behind a person's actions. Nonpharmacological measures should be used first, before administering medications that may be sedating or have other undesirable effects. Box 14.5 lists general nursing principles for the care of older adults with dementia.

Depression

Depression Older adults sometimes experience late-life depression, but it is not a normal part of aging. Depression is the most common, yet most undetected and untreated, impairment in older adulthood. It sometimes exists and is exacerbated in patients with other health problems such as stroke, diabetes, dementia, Parkinson's disease, heart disease, cancer, and pain-provoking diseases such as arthritis. Loss of a significant loved one or admission to a nursing center sometimes causes depression. The Geriatric Depression Scale is an easy-to-use screening tool that can be used in conjunction with an interview with the older adult. Clinical depression is treatable. Treatment includes medication, psychotherapy, or a combination of both. Electroconvulsant therapy (ECT) is sometimes used for treatment of resistant depression when medications and psychotherapy do not help. Of special note, suicide attempts in older adults are often successful. Suicide rates in all age-groups are on the rise over the past several years; the age-group of 85 years of age and older has the second highest suicide rate of all age-groups. Therefore, suicide prevention considerations for older adults are similar to those for the general population.

Prevalence of Depression in Older Adults

Depression remains underdiagnosed and undertreated in the older population and is considered a significant public health issue. Depression is the fourth leading cause of disease burden globally and is projected to increase to the second leading cause by 2030. Approximately 1% to 2% of adults 65 years and older are diagnosed with major depressive disorder. An additional 25% have significant depressive symptoms that do not meet the criteria for major depressive disorder. -Is common in later life -Becoming depressed doubles the probability of becoming sick -Is underdiagnosed and undertreated in older adults

Postfall Assessment

Determination of the reason(s) a fall occurred (postfall assessment [PFA]) is vital and provides information on underlying fall etiologies so that appropriate plans of care can be instituted. Incomplete analysis of the reasons for a fall can result in repeated incidents. The purpose of the PFA is to identify the clinical status of the person, verify and treat injuries, identify underlying causes of the fall when possible, and assist in implementing appropriate individualized risk-reduction interventions. For falls that happen outside the hospital or skilled nursing facility, individuals can complete the "Story of Your Falls" to provide postfall assessment information.

Cognitive Assessment

Determine baseline cognitive status and compare to current status Instruments used for assessment include ◦Mini-Mental State Examination, 2nd edition (MMSE-2) ◦Confusion assessment method ◦Neelon and Champagne (NEECHAM) Confusion Scale

Health Disparities

Differences in HEALTH OUTCOMES between GROUPS

Considerations of Common Changes in Late Life During the Physical Assessment: Extremities

Dorsalis pedis and posterior tibial pulses are very difficult or impossible to palpate. Must look for other indications of vascular integrity.

Erikson's theory of psychosocial development

individuals need to accomplish a particular task before successfully mastering the stage and progressing to the next one. Each task is framed with opposing conflicts, and tasks once mastered are challenged and tested again during new situations or at times of conflict

Medication-Food Interactions

Food may alter medication absorption and/or may contain substances that react with certain medications. -grapefruit/citrus juice: common and can interfere with quite a few meds -calcium and dairy can affect thyroid hormones -vitamin k can decrease anticoagulation -potassium levels

Mini-Mental State Examination

For many years the 30-item Mini-Mental State Examination (MMSE) has been the mainstay for the gross screening of cognitive status. It is used to screen and monitor orientation, short-term memory and attention, calculation ability, language, and ability to correctly copy a figure. There is now a revised 16-item instrument, the MMSE-2, and a slightly longer Expanded Version. Both are reported to be equivalent to the original instrument and are available in multiple languages. To ensure reliability, the nurse must be able to administer them correctly each time they are used. The instruments, permission for use, and instructions for use can be purchased from Psychological Assessments Resources (PAR, http://www.parinc.com).

Gerontological Nursing Roles

Gerontological nursing roles encompass every imaginable venue and circumstance. The opportunities are limitless because we are a rapidly aging society. "Nurses have the potential to improve elder care across settings through effective screening and comprehensive assessment, facilitating access to programs and services, educating and empowering older adults and their families to improve their health and manage chronic conditions, leading and coordinating the efforts of members of the health care team, conducting and applying research, and influencing policy"

Global Aphasia

Global aphasia is the result of large lesions in the left hemisphere of the brain and affects most or all aspects of language. Persons with global aphasia cannot understand words or speak intelligibly. They may use meaningless syllables repetitiously.

Financial abuse

Illegal taking, misuse, or concealment of money, benefits, property, or assets belonging to an elderly person Ex: Check cashing without permission, forging a signature, stealing money or possessions, coercing a signature on legal documents (e.g., will, trust), forcing or improper use of durable power of attorney, unpaid bills, unauthorized credit card use Potter, Patricia A.,Perry, Anne Griffin,Stockert, Patricia,Hall, Amy. Fundamentals of Nursing - E-Book (p. 190). Elsevier Health Sciences. Kindle Edition.

Chronological Aging

In most developed and developing areas of the world, chronological late life is recognized as beginning sometime between the ages 50 and 65, with the World Health Organization using the age of 60 in their discussions. In 1935, with the establishment of a national retirement system (Social Security), the time when one became "old" was set at 65 in the United States. In the 2000s this age is creeping toward 70 when one becomes eligible for pensions and other monetary benefits based on age.

Mandatory Reporting

In most states and U.S. jurisdictions, licensed nurses are "mandatory reporters," that is, persons who are required to report suspicions of abuse to the state, usually to a group called Adult Protective Services (APS) (National Adult Protective Services Association [NAPSA], 2014). The standard for reporting is one of reasonable belief; that is, the nurse must have a reasonable belief that a vulnerable person either has been or is likely to be abused, neglected, or exploited.

Observation

In the observational approach the nurse collects and records objective and subjective data using parameters considered to be objective for performance-based functional assessments (e.g., the distance the person can walk). The usual physical examination includes measurement of objective data such as blood pressure, pulse rate, and respirations, as well as subjective data such as the patient's appearance and level of awareness. Observation and the use of previously developed tools are probably the most accurate assessment methods but they are limited because they only represent a snapshot in time. It is especially dangerous to base conclusions

Reality Orientation`

In the past, structured programs of reality orientation (RO) (orienting the person to the day, date, time, year, weather, upcoming holidays) were often used in long-term care facilities and chronic psychiatric units as a way to stimulate interaction and enhance memory. This intervention is still often noted as being of benefit to persons with NCDs. However, it has been found that structured RO may place unrealistic expectations on persons and may be distressing when persons cannot respond to these questions. Families and professional caregivers can often be heard asking people to name relatives, state their birth year, and remember other current facts. One can imagine how upsetting and demoralizing this might be to a person unable to remember these answers.

Clock Drawing Test

In use since 1992, the Clock Drawing Test is reported to be second in frequency of use to the MMSE across the world. It is not appropriate for use with those who are blind or who have limiting conditions such as tremors, or a stroke that affects their dominant hand. Although reading fluency is not necessary, completion of the Clock Drawing Test requires number fluency, adequate vision and hearing, manual dexterity sufficient to hold a pencil, and experience with analog clocks. This tool cannot be used as the sole measure for dementia but it does test for constructional apraxia, an early indicator. The Clock Drawing Test is an evidence-based instrument that has been found to be useful across cultures and languages and is a sensitive instrument to differentiate among those with and without some level of dementia.

teriparatide (Forteo):

Increases bone formation ·Only used in high risk women and men —those with high risk for fractures ·Expensive ($3600/year) ·Given sub-q ·May promote bone cancer (osteosarcoma) PARATHYROID HORMONES

Safety

Independence with risk is a way of life for frail older adults. At the intersection of risk and safety lie the concerns and preferences of the older adult, family members, and health care team members. Collopy discusses safety as a ubiquitous and conflictive issue in long-term care. At the crux of the debate are issues related to how much risk elderly individuals, family members, and health care professionals are willing to consider acceptable. Opie identified that the argument of safety is a powerful and difficult argument for family to resist. It is helpful if the discussion of safety in the elderly individual's specific situation occurs in such a way that there are opportunities for those involved to develop an understanding of the individual's interpretation about what it means to be safe and to retain the freedom to live as one wants. When there are fewer options available for living safely, or if the options are not consistent with the older adult's viewpoint, the health care decisions may become more difficult.

Informal Sources of Care

Informal care is generally defined as a network of individuals who provide care and support to an older adult, such as family, friends, or neighbors. Families are often both the preferred and actual source of support for three-quarters of impaired older adults who live in the community.

Options

Inherent in the definition of decision-making is the availability of options or choices. Older adults and their families may find that when long-term care is needed, the process is very stressful because there is limited time to make decisions and there are limited choices available. Nolan and Dellasega described the decision-making process associated with finding a nursing home as particularly prone to a lack of individual decisional control because of the lack of discussion between older adults and their families about their wishes, which made the situation more vulnerable to expert external control. Older adults in home care reported that they preferred no help, but recognized that they needed to have some help with activities of daily living (ADLs) to stay in their home. The degree of help that is available through family or community systems may influence decisions about health care.

Research on Aging

Inquiry into and curiosity about aging is as old as curiosity about life and death itself. Gerontology began as an inquiry into the characteristics of long-lived people, and we are still intrigued by them. Anecdotal evidence was used in the past to illustrate issues assumed to be universal. Only in the past 60 years have serious and carefully controlled research studies on aging flourished.

Sleep Disorders

It is important to know (and perhaps to reassure the resident) that although the amount of sleep in 24 hours is unchanged, there are changes in sleep pattern and quality. Impaired sleep can be related to diseases (e.g., restless leg syndrome), medications, or an environment that does not promote good sleep (e.g., room temperature, mattress, noise, roommate habits, etc.). Sleep assessment includes getting a thorough sleep history from the resident and past use of any medications or routines (e.g., exercise) to induce sleep and restfulness. The Pittsburgh Sleep Quality Index (PSQI) is a self-rated instrument that measures sleep quality.10 The Epworth Sleepiness Scale (ESS) is another self-rated instrument that measures excessive daytime sleepiness.11 Both the PSQI and ESS can be used to measure the effectiveness of interventions. Daytime sleepiness is more than a simple need for a daytime nap; it could be iatrogenesis.

Safe Patient Handling

Lifting, transferring, and repositioning patients are the most common tasks that lead to injury for health care staff and patients in hospital and nursing home environments. Handling and moving patients offers multiple challenges because of variations in size, physical abilities, cognitive function, level of cooperation, and changes in condition. Nelson and Baptiste recommend the following evidence-based practices for safe patient handling: (1) patient handling equipment/devices; (2) patient-care ergonomic assessment protocols; (3) no-lift policies; (4) training on proper use of patient handling equipment/devices; and (5) patient lift teams.

Aging Changes: Musculoskeletal System

Ligaments, tendon and joints become dry, hardened and less flexible, muscle mass decreases, thinning of discs in vertebrae causing shortening of trunk, reduced bone mineral density which increases chance of fracture, reduced body water which increases the chance of dehydration -Many are not life threatening but affect someone's ability to function and their quality of life.

Magnetic Field

Like electricity, magnetics has its uses in measurement and treatment, but it also has a dangerous side. Historically, exposure to magnetic fields was not thought to be hazardous. Considerable evidence, however, has emerged on magnetic field exposure and long-term health effects including cancer, fertility difficulty, and numerous other health conditions in various systems of the human body. The magnetocardiogram examines the heart's magnetic field, and the magnetoencephalogram provides information on the head's magnetic field. The magnetoencephalogram can measure brain waves and neuronal and thinking activity by magnetic field changes around the head. This is a profound point. Thinking gives off a measurable field around the head. There is much theoretical discussion about how this field of wave activity then influences the cell membrane through a complex communication system of signals.

The "Welcome to Medicare" Exam

Must be obtained within 12 months of enrolling in Medicare Part B and includes: • Review of medical record • Review of social history related to your health • Education and counseling about preventive services • Health screenings, immunizations, or referrals for other care as needed • Height, weight, and blood pressure measurements • Calculation of body mass index • Simple vision test • Review of risk for depression and level of safety • An offer to discuss advance directives • Written preventive health plan

Sleep Interventions

Nonpharmacologic treatment -First-line treatment -Cognitive behavioral therapy Pharmacologic treatment -Used cautious with older adults -May be used with behavioral interventions Avoid sedative-hypnotics

Nonpharmacological Approaches to Dementia

Nonpharmacological approaches tend to view behavior as stemming from unmet needs, environmental overload, and interactions of individual, caregiver, and environmental factors. The goals of nonpharmacological treatment are prevention, symptom relief, and reduction of caregiver distress. These approaches are resident-centered and include interventions such as meaningful activities tailored to the individual's personality and interests, validation therapy, social contact (real or simulated), animal-assisted therapy, exercise, sensory stimulation, art therapy, reminiscence, Montessori-based activities, environmental design (e.g., special care units, homelike environments, gardens, safe walking areas), changes in mealtime and bathing environments, consistent staffing assignments, bright light therapy, aromatherapy, massage, music, relaxation, distraction, nonconfrontational interaction, and pain management

Care of Individuals With Mild and Major Neurocognitive Disorders

Nurses provide direct care for people with dementia in the community, hospitals, and long-term care facilities. They also work with families and staff, teaching best practice approaches to care and providing education and support. With the rising incidence of dementia, nurses will play an even larger role in the design and implementation of evidence-based practice and provision of education, counseling, and supportive services to individuals with dementia and their caregivers. The overriding goals in caring for older adults with dementia are to maintain function and prevent excess disability, structure the environment and relationships to maintain stability, compensate for the losses associated with the disease, and create a therapeutic milieu that nurtures the personhood of the individual and maintains quality of life.

circadian rhythm sleep disorder

Normal sleep occurs at abnormal times Two types: •Advanced sleep phase disorder (ASPD) •Irregular sleep-wake disorder (ISWD) Treatment (depends on type): •ASPD include hygiene practices and methods to delay the timing of sleep and wake •ISWD include increasing the duration and intensity of light exposure during the daytime

Nursing Research

Nursing research draws from its own body of knowledge, as well as from other disciplines, to describe, monitor, protect, and evaluate the quality of life while aging and the services more commonly provided to the aging population, such as hospice care. Nurses have generated significant research on the care of older adults and have established a solid foundation for the practice of gerontological nursing. Research with older adults receives considerable funding from the National Institute of Nursing Research (NINR).

Depression

Older adults sometimes experience late-life depression, but it is not a normal part of aging. Depression is the most common, yet most undetected and untreated, impairment in older adulthood. It sometimes exists and is exacerbated in patients with other health problems such as stroke, diabetes, dementia, Parkinson's disease, heart disease, cancer, and pain-provoking diseases such as arthritis. Loss of a significant loved one or admission to a nursing center sometimes causes depression. The Geriatric Depression Scale is an easy-to-use screening tool that can be used in conjunction with an interview with the older adult. Clinical depression is treatable. Treatment includes medication, psychotherapy, or a combination of both. Electroconvulsant therapy (ECT) is sometimes used for treatment of resistant depression when medications and psychotherapy do not help. Of special note, suicide attempts in older adults are often successful. Suicide rates in all age-groups are on the rise over the past several years; the age-group of 85 years of age and older has the second highest suicide rate of all age-groups. Therefore, suicide prevention considerations for older adults are similar to those for the general population.

Nutrition and Dementia

Older adults with dementia are particularly at risk for weight loss and inadequate nutrition. Weight loss often becomes a considerable concern in late-stage dementia. Weight loss increases risk for infection, pressure wound development and poor wound healing, and hospitalization, and is associated with higher mortality and morbidity. Predisposing factors include lack of awareness of the need to eat, depression, loss of independence, agnosia, apraxia, vision impairments, wandering, pacing, and behavior disturbances -serve one thing at a time -special utensils or finger foods -cutting things up and easier to feed themselves -sit at the same level when feeding -hand over hand technique

Factors Influencing Mental Health Care: Attitudes and Beliefs

Older individuals with evidence of mental health disorders, regardless of race or ethnicity, are less likely than younger people to receive needed mental health care. Nearly half of people older than age 65 with a recognized mental or substance use disorder have unmet needs for services. Some of the reasons for this include reluctance on the part of older people to seek help because of pride of independence, stoic acceptance of difficulty, unawareness of resources, lack of geriatric mental health professionals and services, and lack of adequate insurance coverage for mental health problems. Stigma about having a mental health disorder ("being crazy"), particularly for older people, discourages many from seeking treatment. Ageism also affects identification and treatment of mental health disorders in older people.

Delirium Superimposed on Mild and Major Neurocognitive Disorders (Dementia)

Older patients with mild and major neurocognitive disorders are three to five times more likely to develop delirium, and it is less likely to be recognized and treated than delirium in a cognitively intact individual. Dementia superimposed on dementia (DSD) can accelerate the trajectory of cognitive decline in individuals and is associated with high mortality among hospitalized older individuals. Changes in the mental status of older adults with dementia are often attributed to underlying dementia, or "sundowning," and not investigated. Despite its prevalence, DSD has not been well investigated, and there are only a few relevant studies in either the hospital or the community setting

Dietary Recommendations for older adults: vitamins and minerals

Older people who consume five servings of fruits and vegetables daily will obtain adequate intake of vitamins A, C, and E and also potassium. Americans of all ages eat less than half of the recommended amounts of fruits and vegetables. After age 50, the stomach produces less gastric acid, which makes vitamin B12 absorption less efficient. Vitamin B12 deficiency is a common and underrecognized condition that is estimated to occur in 12% to 14% of community-dwelling older adults and in up to 25% of those residing in institutional settings. Although intake of this vitamin is generally adequate, older adults should increase their intake of the crystalline form of vitamin B12 from fortified foods such as whole-grain breakfast cereals. Use of proton pump inhibitors for more than 1 year, as well as histamine H2-receptor blockers, can lead to lower serum vitamin B12 levels by impairing absorption of the vitamin from food. Metformin, colchicine, and antibiotic and anticonvulsant agents may also increase the risk of vitamin B12 deficiency (Cadogan, 2010). Calcium and vitamin D are essential for bone health and may prevent osteoporosis and decrease the risk of fracture (see Chapter 21).

Self-transcendence

a sense of authentically connecting to one's inner self. This contrasts with transcendence , the belief that a force outside of and greater than the person exists beyond the material world. Self-transcendence is a positive force. It allows people to have new experiences and develop new perspectives that are beyond ordinary physical boundaries. Examples of transcendent moments include the feeling of awe when holding a new baby or looking at a beautiful sunset.

Consequences of Restraints

Physical restraints, intended to prevent injury, do not protect patients from falling, wandering, or removing tubes and other medical devices. Physical restraints may actually exacerbate many of the problems for which they are used and can cause serious injury and death, as well as emotional and physical problems. Physical restraints are associated with higher death rates, injurious falls, nosocomial infections, incontinence, contractures, pressure ulcers, agitation, and depression. The use of restraints is a great source of physical and psychological distress to older adults and may intensify agitation and contribute to depression. For some older people, especially those with a history of trauma (such as that induced by war, rape, or domestic violence), side rails may cause fear and agitation and a feeling of being jailed or caged

Physiology and Pathophysiology of Parkinson's Disease

Physiology: Two neurotransmitters—Acetylcholine, an excitatory neurotransmitter, and Dopamine, an inhibitory neurotransmitter--in balance=controlled voluntary muscle movements Pathophysiology: Decreased production of Dopamine (no change in acetylcholine)=uncontrolled movements

Pressure Injury Assessment

Pressure injuries are assessed with each dressing change and repeated on a weekly, biweekly, and as-needed basis. The purpose is to specifically and carefully evaluate the effectiveness of treatment. The PUSH tool (Pressure Ulcer Scale for Healing) provides a detailed form that covers all aspects of assessment but contains only three items and takes a short time to complete. Photographic documentation is highly recommended both at the onset of the problem and at intervals during treatment.

Consequences of Pressure Injuries

Pressure injuries are costly to treat and prolong recovery and extend rehabilitation. Complications include the need for grafting or amputation, sepsis, or even death and may lead to legal action by the individual or his or her representative against the caregiver. The personal impact of a pressure injury on health and quality of life is also significant and not well understood or researched. Findings from a study exploring patients' perceptions of the impact of a pressure injury and its treatment on health and quality of life suggest that pressure injuries cause suffering, pain, discomfort, and distress that are not always recognized or adequately treated by nursing staff. Pressure injuries had a profound impact on the patients' lives—physically, socially, emotionally, and mentally

Primary and Secondary Osteoporosis

Primary osteoporosis is so common in women that it is sometimes thought to be part of the normal aging process. Secondary osteoporosis is caused by another disease, such as Paget's disease, or by medications, such as long-term steroid use.

Prompted voiding

Prompted voiding (PV) is a technique used in the nursing home that combines scheduled voiding with monitoring, prompting, and verbal reinforcement. The objective of PV is to increase self-initiated voiding and decrease the number of episodes of UI. Newly admitted nursing home residents who are incontinent (and able to use the toilet) should receive a 3- to 5-day trial of prompted voiding or other toileting programs. The trial can be helpful in demonstrating responsiveness to toileting and determining patterns of and symptoms associated with the incontinence

Describe the special circumstances of pain in those with cognitive or communication limitations

Research has suggested that older people with mild to moderate cognitive impairment can provide valid reports of pain using self-report scales, but people with more severe impairment and loss of language skills may be unable to communicate the presence of pain in a manner that is easily understood. For persons who are no longer able to express themselves verbally either because of dementia or as a result of other neurological conditions such as aphasia, communication of pain usually occurs through changes in behavior, such as changes in ambulation, agitation, aggression, increased confusion, or passivity. Caregivers should be educated to be particularly alert for the latter because the person is less disruptive and this may not be recognized as a change that may indicate pain. alzheimers: lose short-term memory and can not always identify the source of painful stimuli

Racial, Ethnic, and Cultural Considerations of Depression

Studies have consistently found that older racial and ethnic minorities are less likely to be diagnosed with depression than their white counterparts but are also less likely to get treated. Hispanic adults aged 50 and older are reported to experience more depression than white, non-Hispanic adults; black, non-Hispanic adults; or other, non-Hispanic adults. Gender differences are also present in depression prevalence, and older women suffer depression at twice the rate of older men . Differences in the prevalence of major depressive disorder and other mental disorders may be due to differences in the presentation of self-reported symptoms or other aspects of cultural context. The new criteria in the DSM-5 addressing culturally based explanatory models will assist in better understanding differences in presentation, help-seeking behavior, and provision of more culturally appropriate treatment for all individuals. Racial, ethnic, and gender differences in mental illness, as well as differences within racial groups, have not received adequate attention in the United States.

Barthel Index

The Barthel Index (BI) is a quick and reliable instrument for the assessment of both mobility and the ability to perform ADLs. The items are rated in various ways, depending on the item. The BI has been found to be sensitive enough to identify when a person first needs help and to measure progress or decline, especially following a stroke.

Fulmer SPICES

The Fulmer SPICES is a simple and overall assessment tool of older adults focusing on geriatric syndromes. It has proved reliable and valid when used with older persons either in health or with illness, regardless of the setting. The acronym SPICES refers to the sometimes vague but nonetheless very important problems that require nursing interventions: Sleep disorders, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls, and Skin breakdown. Nurses are encouraged to use this acronym as a reference when caring for older adults (see http://www.hartfordign.org). It is a system that alerts the nurse to the most common problems that occur

Functional Independence Measure

The Functional Independence Measure (FIM) was designed to assess a person's need for assistance with ADLs during inpatient stays and for discharge planning, especially following a stroke. In some studies the BI and FIM were found to be comparable. In other studies, the FIM was deemed preferable. The FIM is a highly sensitive functional assessment tool and includes measures of ADLs, mobility, cognition, and social functioning. The tasks are rated using a seven-point scale that ranges from totally independent to totally dependent. Although the FIM is commonly used in acute rehabilitation and Veteran's Administration hospitals in the United States and several other countries, it cannot yet be applied across all countries.

The Global Deterioration Scale

The Global Deterioration Scale is a classic measure of the levels of cognitive changes as one passes through the process of dementia. It uses an ordinal scale from stage 1 (no cognitive decline; i.e., no dementia) to 7 (late-stage dementia; i.e., very severe cognitive decline) and is sensitive enough to show therapeutic changes (e.g., those related to medication adjustments). It is commonly used in the United States, Canada, and many other countries. It is useful to both the nurse and the family to develop appropriate interventions to help the person optimize his or her health and anticipate future needs and changes.

Health Belief Model

The Health Belief Model addresses the relationship between a person's beliefs and behaviors. Has 3 components: 1) involves an individual's perception of susceptibility to an illness. 2) an individual's perception of the seriousness of the illness. This perception is influenced and modified by demographic and sociopsychological variables, perceived threats of the illness, and cues to action (e.g., mass media campaigns and advice from family, friends, and medical professionals). 3)the likelihood that a person will take preventive action. This component results from a person's perception of the benefits of and barriers to taking action. Preventive actions include lifestyle changes, increased adherence to medical therapies, or a search for medical advice or treatment. A patient's perception of susceptibility to disease and his or her perception of the seriousness of an illness help to determine the likelihood that the patient will adopt healthy behaviors. This model helps you understand factors influencing patients' perceptions, beliefs, and behaviors to plan care so that you can more effectively help patients maintain or restore health and prevent illness.

Health Promotion Model

The Health Promotion Model (HPM) defines health as a positive, dynamic state, not merely the absence of disease. Health promotion increases a patient's level of well-being. The HPM describes the multidimensional nature of people as they interact within their environment to pursue health. The model focuses on the following three areas: (1) individual characteristics and experiences; (2) behavior-specific knowledge and affect; and (3) behavioral outcomes, in which the patient commits to or changes a behavior. Each person has unique personal characteristics and experiences that affect subsequent actions. The set of variables for behavioral-specific knowledge and affect influence a patient's motivation to change or adopt healthy behaviors. When applying this model, you modify these variables through nursing actions. Health-promoting behaviors result in improved health, enhanced functional ability, and better quality of life at all stages of development.

Healthy People

The Healthy People initiative provides evidence-based, 10-year national objectives for promoting health and preventing disease. Healthy People provides a framework to help the United States increase its focus on health promotion and disease prevention (instead of illness care) and encourages cooperation among individuals, communities, and other public, private, and nonprofit organizations to improve health

The OARS Multidimensional Functional Assessment Questionnaire (OMFAQ)

The classic instrument, the Older Americans Resources and Services (OARS), was developed at the Center for the Study of Aging and Human Development at Duke University. It was later updated as the OMFAQ. The areas evaluated in the OMFAQ include social and economic resources, mental and physical health, and ADLs. The person's functional capacity in each area is rated on a scale of 1 (excellent functioning) to 6 (totally impaired functioning). At the conclusion of the assessment, a cumulative impairment score (CIS) is calculated ranging from the most capable (6) to total disability (30). An analysis of the data results in (1) an evaluation of the ability, disability, and capacity level at which the person is able to function, and (2) the determination of the extent and intensity of utilization of resources.

Social determinants of health

The conditions in which people are born, grow, live, work, and age, shaped by the distribution of money, power, and resources at global, national, and local levels

Age Stratification Theory

a theory which states that members of society are stratified by age, just as they are stratified by race, class, and gender -age stratification is looking at age categories so young middle aged and old and this is just based on historical content and it's saying you know you can just lump people into these categories

Detective role:

The detective looks for clues and cues about what might be causing distress and how it might be changed. We have to investigate and know as much about the person as possible to be a good detective.

Delirium Etiology

The exact pathophysiological mechanisms involved in the development and progression of delirium remain uncertain. One single cause or mechanism is not likely, but rather emerging evidence supports the theory of complex interaction of biological factors leading to the disruption of neuronal networks. Delirium results from the interaction of predisposing factors (e.g., vulnerability on the part of the individual attributable to predisposing conditions, such as underlying cognitive impairment, functional impairment, depression, acute illness, sensory impairment) and precipitating factors/insults (e.g., medications, procedures, restraints, iatrogenic events, sleep deprivation, bladder catheterization, pain, and environmental factors). A highly vulnerable older individual requires a lesser amount of precipitating factors to develop delirium. The causes of delirium are potentially reversible; therefore accurate assessment and diagnosis are critical. Delirium is given many labels: acute confusional state, acute brain syndrome, confusion, reversible dementia, metabolic encephalopathy, and toxic psychosis.

Sleep

The human organism needs rest and sleep to conserve energy, prevent fatigue, provide organ respite, and relieve tension. Sleep is an extension of rest, and both are physiological and mental necessities for survival. Sleep is a basic need. Rest occurs with sleep in sustained unbroken periods. Sleep occupies one-third of our lives and is a vital function that affects cognition and performance.

The health history

The initiation of the health history marks the beginning of the assessment process. It begins with a review of what the person reports as a problem, known as the "chief complaint." This is considered subjective data that are documented in the patient's own words. In older populations, the "complaint" is often very vague because the interaction of the numbers of chronic diseases, medications used, and other factors obscures what may be a specific or even multifactorial problem. For example, it is not unusual for the person to say, "I just don't feel well."

Need-Driven Dementia-Compromised Behavior Model

The need-driven dementia-compromised behavior (NDDB) model is a framework for the study and understanding of behavioral symptoms of dementia. All behaviors have meaning and are a form of communication, particularly as verbal communication becomes more limited. Rather than behavior being viewed as disruptive, it is viewed as having meaning and expressing needs. Behavior reflects the interaction of background factors (cognitive changes as a result of dementia, gender, ethnicity, culture, education, personality, responses to stress) and proximal factors (physiological needs such as hunger or pain, mood, physical environment [e.g., light, noise, temperature]) with social environment (e.g., staff stability and mix, presence of others)

Outcome and Assessment Information Set (OASIS-C1)

The skilled care provided in the home is based on, and documented in, the Outcome and Assessment Information Set (OASIS) (CMS, 2012). Now in its third revision (OASIS-C), further modifications were effective October 1, 2014 (OASIS-C1). The assessment is very comprehensive and focuses on the development of interventions to prevent rehospitalization and ensure safety in the home setting. Among the items on the instrument are those that identify the person's risk for hospitalization. The majority of the documentation takes place in the patient's home and is entered into a laptop or tablet for transmission to the agency database, and ultimately to the Centers for Medicare and Medicaid Services. Completion is required for all care that is compensated by Medicare or Medicaid, and forms the basis for the level of reimbursement. As with other instruments, the assessment is completed at the time the care is begun and at intervals thereafter. Nurses supplement the OASIS data with information necessary to personalize the care provided. It is exceedingly complex and training is required. For more information, see http://www.cms.gov or search OASIS-C.

Drug interactions

When two or more medications or foods are taken together or close together, they may cause a change in the effectiveness of the other -Polypharmacy increases the risk for and the frequency of medication-medication interactions The more medications a person takes, the greater the possibility that one or more of them will interact with each other, with an herbal product, with a nutritional supplement, with food, or with alcohol. When two or more medications or foods are taken together or close together, the drugs may potentiate one another; that is, one may increase the effectiveness of the other.

Health Literacy

a person's capacity to learn about and understand basic health information and services, and to use these resources to promote one's health and wellness

Wheelchairs

Wheelchairs are a necessary adjunct at some level of immobility and for some individuals, but they are overused in nursing homes, with up to 80% of residents spending time sitting in a wheelchair every day. Often, the individual is not assessed for therapeutic treatment and restorative ambulation programs to improve mobility and function. Improperly maintained or ill-fitting wheelchairs can cause pressure ulcers, skin tears, bruises and abrasions, and nerve impingement, and they account for 16% of nursing home falls. It is important that a professional evaluate the wheelchair for proper fit and provide training on proper use, as well as evaluate the resident for more appropriate mobility and seating devices and ambulation programs. There are many new assistive devices that could replace wheelchairs, such as small walkers with wheels and seats. If the person is unable to ambulate without assistance, the person should be seated in a comfortable chair with frequent repositioning and wheelchairs should be used for transport only.

Pharmacological Treatment of Constipation

When changes in diet and lifestyle are not effective, the use of laxatives can be considered. Use of these medications, both prescribed and OTC, is high. The extensive use of laxatives among older adults in the United States can be considered a cultural habit. During earlier times, weekly doses of rhubarb, cascara, castor oil, and other types of laxatives were consumed and believed by many to promote health. The belief that cleaning out the colon and having a daily bowel movement is paramount to maintaining good health still persists in some groups. Providing information about normal bowel function, definition of constipation, and lifestyle modifications can assist in promoting healthy bowel habits without the use of laxatives. If laxatives are indicated, those commonly used in chronic constipation include the following: • Bulking agents (e.g., psyllium, methylcellulose) • Stool softeners (surfactants) (e.g., docusate sodium) • Osmotic laxatives (e.g., lactulose, sorbitol) • Stimulant laxatives (e.g., senna, bisacodyl) • Saline laxatives (e.g., magnesium hydroxide [Milk of Magnesia])

E—Elimination

While difficulties with bowel and bladder functioning are not normal parts of aging, they are more common than they are in younger adults and can be triggered by such things as immobility attributable to physical limitations (e.g., following a stroke) or medications (e.g., diuretics). Incontinence can result from cognitive changes that may cause reduction, or even absence, of the sensation indicating a need to void or defecate. There are many elimination problems for older adults living in institutional settings where they are dependent on others for assistance to maintain continence (e.g., getting to the toilet in time). Is the person having difficulty with bladder or bowel elimination? Is there a lack of control? Does the environment interfere with elimination and related personal hygiene (e.g., are toileting facilities adequate and accessible)? Are any assistive devices used, such as a high-rise toilet seat or bedside commode, and if so, are they available and functioning? If there are problems, how are they affecting the person's social functioning and self-esteem?

Constipation

a reduction in the frequency of stool or difficulty in formation or passage of stool •One of the most common gastrointestinal complaints encountered in clinical practice •Associated with impaired quality of life, significant health care costs, fecal impaction, bowel obstruction, cognitive dysfunction, delirium, falls, and increased morbidity and mortality

The Executive Interview

a 25- item examination tool that incorporates a variety of tests of executive function (i.e., the cognitive ability to organize information), as well as planning, initiating, and regulating complex behaviors. Testing executive function yields valuable information that goes beyond simple orientation and can offer insight into how well or poorly organized the patient's cognitive processes are. The test is scored on a 0-, 1-, or 2-point scheme on each item. A score of 15 or more is indicative of executive dysfunction. The test takes approximately 20 minutes to administer, and directions on the test itself explain how to perform each item, making it easy to administer with a little practice.

Spiritual Wellness

a feeling of unity or oneness with people and nature and a sense of life's purpose, meaning, or value; for some, a belief in a supreme being or religion

Obesity in Older Adults

an increasing concern as older adults age -associated with increased costs in healthcare, functional impairments, disability, chronic disease and nursing home admission -consider weight loss recommendations carefully and on an individual basis

At 10 PM, an older male cognitively intact resident in a nursing home attempts to climb over the bedrails. Which intervention should the nurse implement first? a. Talk to the resident about his behavior. b. Call the physician, and ask for a sedative. c. Apply a vest restraint on the resident. d. Get a companion to keep him in the bed.

a. Talk to the resident about his behavior.

Short Term Memory

activated memory that holds a few items briefly minutes to days

Acute stage of chronic illness

active illness or complications that require hospitalization for management

The Urinary Incontinence Assessment in Older Adults

addresses frequency of urination, leakage, and discomfort when urinating. It also contains the "Impact Questionnaire," which addresses the extent to which UI or leakage has affected the individual's ability to perform household tasks and engage in recreational and social activities, as well as his or her emotional well-being (e.g., feeling depressed).

Health Belief Model

addresses the relationship between a person's beliefs and behaviors (positive or negative) 1st component: of this model involves an individual's perception of susceptibility to an illness. -ex: pt family member died from myocardial infarction perceives a risk of heart disease. 2nd component is an individual's perception of the seriousness of the illness. This perception is influenced and modified by demographic and sociopsychological variables, perceived threats of the illness, and cues to action -ex: pt may not perceive his heart disease as serious and may not take care of himself 3rd component is the likelihood that a person will take preventive action. This component results from a person's perception of the benefits of and barriers to taking action. Preventive actions include lifestyle changes, increased adherence to medical therapies, or a search for medical advice or treatment.

Aphasia

affects a person's ability to use and understand spoken or written words and is the results of damage to the side of the brain dominant for language

Faith

allows people to have firm beliefs despite lack of physical evidence. Faith enables people to believe in and establish transpersonal connections. Although many people associate faith with religious beliefs, it also exists without them. For example, one might have faith that all people are good, without being a practitioner of a religion. -In addition to being a component of spirituality, the concept of faith has other definitions. It is a cultural or institutional religion such as Judaism, Buddhism, Islam, or Christianity. It is also a relationship with a divinity, higher power, or spirit that incorporates a reasoning faith (belief) and a trusting faith (action). Reasoning faith provides confidence in something for which there is no proof. It is an acceptance of what reasoning cannot explain. Sometimes faith involves a belief in a higher power, spirit guide, God, or Allah. It is also the way a person chooses to live. It gives purpose and meaning to an individual's life, allowing for action.

Cross-Link Theory

an accumulation of cross-linked proteins resulting from the binding of glucose to protein causes various problems

Adverse Drug Reactions

an unwanted pharmacological effect such as a minor rash or nausea. -polypharmacy, reduced organ function and physiological reserve, and varying levels of skills of health care providers put older adults at greater risk for adverse drug reactions (ADRs) and adverse drug events (ADEs). -when a reaction reaches the level of harm, it is referred to as an adverse drug event and includes adverse drug withdrawal and therapeutic failures. Many of these must be reported to the U.S. Food and Drug Administration or other regulatory bodies. -most common in those over 65 years of age.

Wear and Tear Theory

as time goes by, repeated use and abuse of the body's tissues cause it to be unable to repair all the damage

The ABCDEs of detecting melanoma

asymmetry, border, color, diameter, evolving

What cognitively should stay stable in a normal aging adult?

attention span, language, communication, understanding, and visual perception -ultimately the aging brain maintains resiliency or the ability to compensate for age related changes

Health Inequities

avoidable inequalities in health between groups of people within countries and between countries

Post-traumatic stress disorder (PTSD)

begins when a person experiences or witnesses a traumatic event and responds with intense fear or helplessness. PTSD is common among military personnel and veterans and police, particularly soldiers who have been involved in combat or police involved in violent acts. Soldiers often witness or participate in disturbing events, producing dramatic symptoms. Some other examples of traumatic events that lead to PTSD include motor vehicle crashes, natural disasters, or violent personal assault. Anxiety associated with PTSD is sometimes manifested by nightmares and emotional detachment. Some people with PTSD experience flashbacks, or recurrent and intrusive recollections of the event. Depression and PTSD commonly occur together

Connectedness

being intrapersonally connected within oneself; interpersonally connected with others and the environment; and transpersonally connected with God or an unseen higher power. Through connectedness patients move beyond the stressors of everyday life and find comfort, faith, hope, and empowerment.

Types of Incontinence

can be classified by acute and chronic -stress incontinence: with activity and increased abdominal pressure -urge incontinence: sometimes cause by infection or neurological disorder; can't supress the need to go to the bathroom -mixed: can be urge and stress; often high post-void residual; can cause dribbling, hesitancy, inability to start the flow of urine -functional: the environmental barriers; things like wheelchair, zippers, clothing,

Stable stage of chronic illness

controlled illness course/symptoms

Custodial grandparents

grandparents who have legal custody of their grandchildren when adult children are unable to provide adequate care -2.6 mill grandparents are raising their grandchildren (30% increase in last 30 yrs) -1/10 grandchildren co-reside with their grandparents -grandparents and other relatives save taxpayers about 4 billion/yr in foster care costs

Hope

has several meanings that vary on the basis of how it is being experienced; it usually refers to an energizing source that has an orientation to future goals and outcomes.

What is a true statement about depression or depression therapy? a. An older adult who lived through the Great Depression is unlikely to develop depression. b. Cognitive behavioral therapy is never effective. c. Electroconvulsive therapy (ECT) is rarely a successful treatment option for depression in older adults. d. The nurse should avoid trying to bolster a depressed person's mood or deny his or her despair

d. The nurse should avoid trying to bolster a depressed person's mood or deny his or her despair

Sexuality

includes the physical act of intercourse and other types of physical activity -sex is a basic need

Dysphagia

difficulty swallowing or eating -affects a persons nutritional intake -obtain a hx of responses to dysphagia -observe and pay attention to this - watch during meal times to determine risk -often because of neurologic disease, dementia or behavioral, sensory or motor problems -swallowing studies are often done -important we assume that older adults are at risk for aspirations if swallowing study is ordered -Maintain NPO status until the evaluation is completed -Nutrition and hydration needs can be met by intravenous, nasogastric, or gastric tubes

Diversity

existence of more than one group with differing values and perspectives

cultural pre-competence

explore cultural issues, are committed, assess needs of organization and individuals

post fall assessment

fall circumstances medical problems medication review mobility vision and hearing neurologic: VS cardiovascular assessments Determining the reason for a fall occurred provides information about the cause of a fall and ensures that appropriate plans can be instituted to prevent future falls -watch person for 48 hours after -orthostatic bp

Social Security

federal program of disability and retirement benefits that covers most working people Social Security was designed as a pay-as-you-go system. Payroll taxes collected from employees and employers are immediately distributed to beneficiaries (retirees, the disabled, eligible spouses, or children). Although individually deposited, the revenues are not reserved for any one individual; that is, no one has an account reserved in his or her name. All funds that are not immediately paid to beneficiaries are "borrowed" by the federal government for regular operating expenses.

Social Security

federal program of disability and retirement benefits that covers most working people •Calculation has been most beneficial to older white men; worked most consistently at higher salaries than any other group •Least beneficial for persons of color and many women who took time off for child or parent care, or were paid in cash •Designed as a pay-as-you-go system •An age entitlement program •Age of eligibility has increased over time

The Kennedy Terminal Ulcer

first described in 1989 and now explained as an unavoidable skin breakdown that occurs during the dying process, presents as a red, yellow, or purple lesion shaped like a pear, butterfly, or horseshoe on the coccyx or sacrum. The lesion will darken deeply and progress to a full-thickness ulcer in a few days, and usually indicates that death is imminent. The consensus statement concludes that these changes can be an unavoidable part of the dying process and may occur even with appropriate evidence-based interventions.

fluid and crystallized intelligence

fluid intelligence: one's ability to reason speedily and abstractly; tends to decrease during late adulthood. crystallized intelligence: one's accumulated knowledge and verbal skills; tends to increase with age

Secondary Prevention

focuses on preventing the spread of disease, illness, or infection once it occurs. Activities are directed at diagnosis and prompt intervention, thereby reducing severity and enabling the patient to return to a normal level of health as early as possible. Examples include identifying people who have a new case of a disease or following people who have been exposed to a disease but do not have it yet. It includes screening techniques and treating early stages of disease to limit disability by averting or delaying the consequences of advanced disease. Screening activities may lead to primary prevention intervention. For example, a nurse screens a patient who is obese for diabetes. After gathering more information from the patient, the nurse provides health education about physical activity and preventing hypertension. DETECT

Motivation:

force that acts on or within a person to cause them to act a certain way

cultural destructiveness

forced assimilation, subjugation, rights and privileges for dominant groups only

Physical Wellness

good physical fitness and confidence in your personal ability to take care of health problems

Metabolism

how the body modifies the chemical structure of the drug - converts it to a metabolite -active metabolites not in right place can have adverse effects -primary metabolism organ is the liver

Distribution

how the medication is sent to a target organ -depends on plasma proteins (especially albumin) -older adults have a small decrease in albumin (more medication left in the wrong place) -change in body composition that can impact distribution - decrease in water, increase in fat, decrease in lean body mass

What happens to cognition in aging?

how we have this executive functioning and know what to do so cognition can remain stable or decline with aging but the older brain may respond more slowly that's because of processing time

Unstable stage of chronic illness

illness course/symptoms not controlled by regimen but not required or desiring hospitalization

Collaborative care models

include a primary care provider (PCP, an MD or NP), care management staff (often nurses), and a psychiatric consultant working in an interprofessional team. Care managers are trained to provide evidence-based care coordination, brief behavioral interventions/psychotherapy, and treatment support initiated by the PCP, such as medications. The psychiatric consultant, either through face-to-face or by telemedicine consult, advises the team and provides guidance on patients who present diagnostic challenges or who are not yet showing improvement

urinary tract infection (UTI)

infection of one or more organs of the urinary tract -Most common cause of bacterial sepsis in older adults -10 times more common in women than in men -May be difficult to detect: •Older individuals do not report classic symptoms •Cognitively impaired residents may not recall or report symptoms •can have no symptoms and a lot of times the first symptom is confusion

Neuropathic pain

involves a pathophysiological process of the peripheral or central nervous system and presents as altered sensation and discomfort. This type of pain may be described as stabbing, tingling, burning, or shooting.

Caring for patients with chronic illness

is a combination of addressing acute events that are superimposed on underlying conditions. It is curing what can be cured, providing comfort, and assuring that the person receives optimal, evidence-based care for that which is chronic. Individuals with chronic conditions need care that is coordinated across time and centered on their needs, values, and preferences. They need self-management skills to minimize long-term complications and that help them know when to seek help. They need health care providers (including nurses) who understand the fundamental differences between episodic illness to be cured and chronic conditions to be managed over many years and over periods of stability and instability. Interventions must take into consideration all of the information learned in the assessment to work with the individual and significant others to help the person develop personal goals and achieve these whenever possible.

Assessment of the elder with a chronic illness

is a holistic and interactive process. In no other situation is it necessary to consider all aspects of a person: physiological, psychological, social, spiritual, and functional. Each aspect is affected by the presence of the disease and in the context of the person's culture. Tools can be found throughout the text that can be used for assessment purposes, both comprehensive and specific related to the chronic condition and development of an acute process. Since a chronic disease is an evolving one, so is the need for, and type of, assessment. There is the need for nursing skills to conduct ongoing evaluation of responses and outcomes, careful observation, periodic monitoring, alert watchfulness, and (most importantly) discussion and collaboration with elders about their perceptions, the meaning of their illness, and their plans for the future. The assessment helps identify the gap between the existing patient self-care abilities and needed self-care resources.

Rapid transcranial magnetic stimulation (rTMS)

is a treatment approved in 2008 by the FDA to treat major depressive disorder in adults for whom medication was not effective or tolerated. The treatment consists of administering brief magnetic pulses to the brain by passing high currents through an electromagnetic coil adjacent to the patient's scalp. The targeted magnetic pulses stimulate the circuits in the brain that are underactive in patients with depression with the goal of restoring normal function and mood. For most patients, treatment is administered in 30- to 40-minute sessions over a period of 4 to 6 weeks. The effectiveness of the treatment is still being evaluated in older adults.

The Confusion Assessment Method (CAM)

is another useful tool in evaluating delirium, which can greatly affect capacity. The CAM was designed as a tool to enable nonpsychiatric clinicians to assess delirium in the clinical and research setting. It is available in both short- and longform versions. It assesses the course of the delirium, disorganized thinking, disorientation, memory deficits, perceptual disturbances, and agitation. Using instruments such as these can provide a good measurement of baseline functioning, as well as provide measures of mental functioning that can be useful in cases where the courts or social agencies request objective data regarding a patient's mental status.

Nociceptive pain

is associated with injury to the skin, mucosa, muscle, or bone and is usually the result of stimulation of pain receptors. This type of pain arises from tissue inflammation, trauma, burns, infection, ischemia, arthropathies (rheumatoid arthritis, osteoarthritis, gout), nonarticular inflammatory disorders, skin and mucosal ulcerations, and internal organ and visceral pain from distention, obstruction, inflammation, compression, or ischemia of organs. Nociceptive mechanisms usually respond well to common analgesic medications and nonpharmacological interventions.

Electroconvulsive therapy (ECT)

is considered an excellent, safe therapy for older people with depression that is resistant to other treatments and for patients at risk for serious harm because of psychotic depression, suicidal ideation, or severe malnutrition. ECT results in a more immediate response in symptoms and is also a useful alternative for frail older people with multiple comorbid conditions who are unable to tolerate antidepressant treatment. ECT is much improved, but older people will need a careful explanation of the treatment because they may have many misconceptions.

Primary Prevention

is true prevention. Its goal is to reduce the incidence of disease. Many primary prevention programs are supported by the government (e.g., federally funded immunization programs). Primary prevention includes health education programs, nutritional programs, and physical fitness activities. It includes all health promotion efforts and wellness education activities that focus on maintaining or improving the general health of individuals, families, and communities. Examples of primary prevention include promoting hearing protection in occupational settings and providing education to reduce cardiac disease risk factors. PREVENT

Life Review

life review is a more formal therapy technique than reminiscing is but it takes a person through his or her life in this structured in chronological order

Crisis phase of chronic illness

life-threatening situation because of chronic illness

Gerotranscendence Theory

looking at aging as this ever-evolving process that changes somebody's view of reality it changes their spirituality their meaning beyond themselves and so a person may withdraw from society to give themselves time for self-reflection

Modernization Theory

looking at the value and how technology urbanization and mass education have changed things -similar to social exchange theory

Intermittent catheterization

may be used in people with urinary retention related to a weak detrusor muscle (e.g., diabetic neuropathy), those with a blockage of the urethra (e.g., benign prostatic hypertrophy), or those with reflux incontinence related to a spinal cord injury. The goal is to maintain 300 mL or less of urine in the bladder. Most of the research on intermittent catheterization has been conducted with children or young adults with spinal cord injuries, but it may be useful for older adults who are able to self-catheterize. It provides an important alternative to indwelling catheterization.

age associated memory impairment

memory loss that is considered normal and light of a person's age and educational level. the general slowness in processing, storing, and recalling new information, difficulty remembering names and words

Risk factors for osteoporosis

nonmodifiable: -gender (female) -race: white or asian (african american less so) -age: postmenopausal in age -family history modifiable: -underweight -small stature -diet low in calcium -diet high in caffeine, alcohol consumption -hormone deficiencies -low activity level -certain meds: steroids, anticonvulsants, thyroid meds -smoking

Gerontological Nursing

nursing practice that promotes wellness and highest quality of life for aging individuals

Postprandial hypotension (PPH)

occurs after ingestion of a carbohydrate meal and may be related to the release of a vasodilatory peptide. PPH is more common in people with diabetes and Parkinson's disease but has been found in approximately 25% of persons who fall. Lifestyle modifications such as increasing water intake before eating or substituting six smaller meals daily for three larger meals may be effective, but further research is needed. All older persons should be cautioned against sudden rising from sitting or supine positions, particularly after eating.

Tertiary Prevention

occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration. Activities are directed at rehabilitation rather than diagnosis and treatment. For example, a patient with a spinal cord injury undergoes rehabilitation to learn how to use a wheelchair and perform activities of daily living independently. Care at this level helps patients achieve as high a level of functioning as possible, despite the limitations caused by illness or impairment TREAT

Informal caregiver

one who provides unpaid assistance to one who has some physical, mental, emotional, or financial need limiting his or her independence -unpaid family members are the largest source of long-term care services in America -most informal caregivers are women (daughters and dil)

Crystallized Intelligence

our accumulated knowledge and verbal skills; tends to increase with age -the knowledge and abilities that we get through education and life -often stays stable in older adults -ex: memorizing things, solving big math problems, learning to speak more than one language

Bladder Diary

outlines time, amount, type of fluid intake and time, each void. precipitating events. -record over 3-7 days

Myth about pain

pain is a normal part of aging (does increase, but not inevitable), if pain isn't reported it isn't there (stoic, unable to respond, other barriers) narcotics are inappropriate (start small doses and often best meds for it)

Continuity theory

people should develop and maintain this consistent pattern of behavior over a lifetime and as they age that shouldn't change so they should have this stable personhood. thinks that successful aging means that they were able to continue their previous behaviors and roles or find something that's a suitable replacement -might work for some but wouldn't necessarily work for everybody

Self-efficacy:

person's perceived ability to successfully complete a task

Dying stage of chronic illness

progressive decline in physical/mental status characterized by increasing disability/symptoms -immediate weeks, days, hours preceding death

Downward stage of chronic illness

progressive decline in physical/mental status characterized by increasing disability/symptoms -increase in symptoms

Reminiscing

recalling the past -should provide something that the the older adult enjoys -thinking back on their life -increases their socialization -often done with family or friends or caregivers -good for communication and effort, personal growth, can decrease depression scores

Fecal Impaction

•Common in incapacitated and institutionalized older people •Symptoms include malaise, urinary retention, elevated temperature, incontinence of bladder or bowel, alteration in cognitive status, fissures, hemorrhoids, and intestinal blockage •Treat with oil-retention enemas and digital removal

Catheter-associated urinary tract infections (CAUTIs)

refer to urinary tract infections that occur in a patient with an indwelling catheter or within 48 hours of catheter removal. CAUTIs are the most common hospital-acquired infection worldwide. One of the goals of Healthy People 2020 is to prevent, reduce, and ultimately eliminate health care-associated infections. Implementation of evidence-based guidelines, catheter reminders, stop orders, nurse-initiated removal protocols, and a urinary catheter bundle can decrease CAUTIs in acute care

Geriatric Syndromes

refers to a sign or symptom, or a group of specific signs and symptoms, that occur more often in older adults than in younger adults. -multiple etiological and pathological pathways of some of the geriatric syndromes. -contributing factors include multiple chronic diseases, normal age-related changes, polypharmacy, multiple providers, and the adverse effect of therapeutic or diagnostic interventions. -SPICES is an effective way to assess -can be an outcome of iatrogenesis & frailty. -impact on morbidity and mortality. -multiple causes and risk factors -involves multiple organ systems -occurs primarily in older persons ex: •Falls and gait abnormalities •Frailty •Delirium •Urinary Incontinence •Sleep Disorders •Pressure Ulcers

Oxidative Stress Theory

rise in the level of ROS (reactive oxygen species) can come from things like pollution, inflammation in the body, or other environmental factors such as smoking. The increase in ROS ultimately leads to cell death. Cells are no longer able to function. The damage that happens is random and unpredictable. Some people can have a lot of these risk factors and not have cell death.

Dysarthria

second in incidence only to aphasia, is most often seen in persons following a stroke or the neurological brain damage associated with another cause such as traumatic injury. It is an impairment in the ability to articulate words as the result of damage to the central or peripheral nervous system that affects the muscle control needed for speech. Muscle weakness or incoordination interferes with the clarity of speech and pronunciation. Speech may be slow, jerky, slurred, quiet, lacking in expression, and difficult to understand. It may involve a weakness in any one or more of the several mechanisms of speech, such as respiration, phonation, resonance, articulation, and prosody (the meter, or rhythm of speech). For example, if the respiratory system is weak, then speech may be too quiet or be produced one word at a time. If the laryngeal system is weak, speech may be breathy, quiet, and slow. If the articulatory system is affected, speech may sound slurred and be slow and labored. •Impairment in the ability to articulate words (motor based) •Treatment includes alternative and augmentative speech aids •caused by weakness or incoordination of the speech muscles due to damage to the CNS or PNS - exact way it looks depends on where the damage is •generally characterized by weakness, slow movement, and lack of coordination of the muscles associated with speech •when speech happens: slow, jerky, slurred, quiet, lack of expression PAY ATTENTION, PATIENT

FANCAPES

setting. It is a model for a comprehensive yet prioritized, primarily physical assessment that is especially useful for the frail elder (Resnick & Mitty, 2009). It emphasizes the determination of very basic needs and the individual's functional ability to meet these needs independently. It can be used in all settings, may be used in part or whole depending on the need, and is easily adaptable to functional pattern grouping if nursing diagnoses are used. Fluids Aeration Nutrition Communication Activity Pain Elimination Socialization

Trajectory phase of chronic illness

signs and symptoms are present, includes diagnostic period

three-legged stool

social security, pensions, savings/assets

Meaning and purpose in life

spirituality also helps people find meaning and purpose in both positive and negative life events.

Inner strength and peace

spirituality gives people the ability to find a dynamic and creative sense of inner strength to use when making difficult decisions. This source of energy helps people stay open to change and life challenges, provides confidence in decision making, and promotes connections with others and a positive outlook on life. Inner peace fosters calm, positive, and peaceful feelings despite life experiences of chaos, fear, and uncertainty. These feelings help people feel comforted even in times of great distress.

Mini-Mental State Examination (MMSE)

tests orientation, registration, attention and calculation, recall, and ability to follow commands. It takes approximately 5 to 10 minutes to administer, with a maximum score of 30 on 17 items. Scores of 23 or less indicate patients with diagnoses of dementia, schizophrenia, delirium, or affective disorders. Scores above 24 are considered within the normal range

Occupational Wellness

the ability to perform your job skillfully and effectively under conditions that provide personal and team satisfaction and adequately reward each individual

Social Wellness

the ability to relate well to others, both within and outside the family unit

Fluid Intelligence

the ability to see abstract relationships and draw logical inferences -consists of skills that are determined biologically, independent of experience or learning -older adults might become poorer in these areas -ex: navigating a subway system in the city that they haven't been before, assembling a piece of furniture using a diagram, or solving puzzles

Intellectual Wellness

the ability to think clearly, reason objectively, analyze, and use brain power to solve problems and meet life's challenges

Emotional Wellness

the ability to understand your own feelings, accept your limitations, and achieve emotional stability

Neuroplasticity

the ability within the brain to constantly change both the structure and function of many cells in response to experience or trauma

Opression

the act of keeping someone down through harsh and unjust use of power

Iatrogenesis

the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence.

Pharmacokinetics

the movement of drugs in the body from administration to excretion -includes absorption, distribution, metabolism and excretion -There is no conclusive evidence of an appreciable change in overall pharmacokinetics with aging; however, several normal age-related physiological changes have implications for safe drug use in later life -In particular, these changes significantly increase the risk for adverse reactions or unpredictable effects.

Among the predisposing factors for iatrogenesis among older adults, the most likely culprits are:

the number of prescribed medications and polypharmacy (as well as OTC and use of herbal remedies), atypical presentation of illness, and more comorbid chronic illnesses. Impaired cognitive and functional capacity, reduced physiologic reserve, and altered compensatory mechanisms add to the risk.

cultural blindness

the process of ignoring differences in people and proceeding as though the differences do not exist

Long Term Memory

the relatively permanent storage of information years

Epigenetics

the study of environmental influences on gene expression that occur without a DNA change Our genes are not fixed; we are not simply genetically determined. Our genes are modulated by our inner environment—the emotional, chemical, mental, energetic, and spiritual landscape—as well as our outer environment—the social and ecological systems in which we reside. Genes may be activated or deactivated by the meaning we assign to an experience. Truly we are formed and molded by the thoughts that stimulate the formation of neural pathways that either reinforce old patterns or initiate new ones.

Polypharmacy

the use of five or more medications or the use of multiple medications for the same problem -increases mortality and morbidity -increases falls Polypharmacy may occur "accidentally" if an existing drug regimen is not considered when new medications are prescribed.

Social Exchange Theory

thinks that as somebody ages they might have fewer and fewer resources economically to contribute to society. Ex: no job anymore, losing social status and potentially self esteem and power -those who can maintain that power and stay more of a full participating member of society will have better aging

Osteopenia

thinner than average bone density

What happens once it is determined that a patient does have capacity?

this should be specifically documented in the medical record. In cases where the decision is made that the patient lacks decision-making capacity, a surrogate decision-maker must be appointed. -In most states, the order of preference for surrogates is spelled out in some fashion in the mental health codes. It usually falls initially to the spouse, then to the parents, adult children, adult siblings, or to a person previously designated by a power of attorney

Disengagement theory

thought that in the natural course of aging the person does and should withdraw from society to allow that transfer of power to younger generations. they thought that this was necessary for social equilibrium but this sort of provided the basis for age discrimination. For example, when someone younger came into a job for it was often known and good that they would take the place of this older individual even if they weren't really ready to retire. so this is no longer considered an indicator of successful aging but I think still happens sometimes

Health inequities

when there is an excess burden of illness or difference between expected incidence and prevalence of one group compared to the population -often due to distribution of wealth -affect health outcomes

calcitonin (Miacalcin):

·Hormone, inhibits bone resorption ·Nasal spray or injection (given every other nostril) HORMONE

General Nursing Interventions in Care of Persons With Dementia

• Address safety. • Structure daily living to maximize remaining abilities. • Monitor general health and impact of dementia on management of other medical conditions. • Provide meaningful activities and relationships to enhance quality of life. • Support advance care planning and advance directives. • Educate caregivers in the areas of problem-solving, resources access, long-range planning, emotional support, and respite care.

common developmental tasks of older adults

• Adjusting to decreasing health and physical strength • Adjusting to retirement and reduced or fixed income • Adjusting to death of a spouse, children, siblings, friends • Accepting self as aging person • Maintaining satisfactory living arrangements • Redefining relationships with adult children and siblings • Finding ways to maintain quality of life • Linked to the concept of developmental tasks appropriate for stages in life (deaths of friends and significant others, retirement and reduced or fixed income, changes in quality of life or living arrangements) • Structural and functional changes (failing health and physical strength) • Self-acceptance

Precipitating Factors for Delirium

• Age greater than 65 years • Cognitive impairment • Severe illness or comorbidity burden • Hearing or vision impairment • Current hip fracture • Presence of infection • Inadequately controlled pain • Polypharmacy and use of psychotropic medications (benzodiazepines, anticholinergics, antihistamines, antipsychotics) • Depression • Alcohol use • Sleep deprivation or disturbance • Renal insufficiency • Aortic procedures • Anemia • Hypoxia or hypercarbia • Poor nutrition • Dehydration • Electrolyte abnormalities • Poor functional status • Immobilization or limited mobility • Risk of urinary retention or constipation • Use of invasive equipment, restraints

Nursing Assessment Questions Regarding Sexuality

• Are you sexually active? • With whom do you have sex: men, women, or both? • How many sexual partners do you have (or have you ever had)? • How do you feel about the sexual aspects of your life? • Have you noticed any changes in the way you feel about yourself? • How has your illness, medication, or surgery affected your sex life? • It is not unusual for people with your condition to be experiencing some sexual changes. Have you noticed any changes, or do you have any concerns? • Are you in a relationship in which someone is hurting you? • Has anyone ever forced you to have sex against your will? • Tell me what you know about safe sex practices, use of contraceptives, or prevention of sexually transmitted infections. • Tell me the safe sex practices that you follow.

Key Points to Consider in Observing Cultural Rules and Etiquette

• Be aware of past experiences in the health care setting. • Ask if there are persons (e.g., males in the family) that need to be present or involved in some way with the exam. • Respect the communication style used, especially in the health care setting. • Do not intrude into personal space without permission. • Be aware of general health orientation related to time (past, present, future). • Inquire as to appropriate wording reference to the person; presume using last name unless otherwise welcomed. • Inquiry as to acceptable level of touch and gender of provider.

Constitutional Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Change in the level of energy

Neurological Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Changes in sensation, especially in extremities • Changes in memory other than very minimal • Ability to continue usual cognitive activities • Changes in sense of balance or episodes of dizziness • History of falls, trips, slips

Urinary Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Changes in urine stream and length of time condition has been present; difficulty starting stream • Incontinence and, if present, under what circumstances and degree; personal strategies used to address urinary incontinence (e.g., pads)

Senses Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Changes in vision or hearing acuity and situations in which changes occur, or complaints of others related to these changes • Increase in dental caries, changes in taste, presence of bleeding gums, level of current dental care • Changes in smell

Risk Factors for Depression

• Chronic medical illnesses, disability, functional decline • Alzheimer's disease and other dementias • Bereavement • Caregiving • Female (2 : 1 risk) • Socioeconomic deprivation • Family history of depression • Previous episode of depression • Admission to long-term care or other change in environment • Medications • Alcohol or substance abuse • Living alone • Widowhood

Gastrointestinal Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Continence, constipation, bloating, anorexia

Vascular Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Cramping of extremities, decreased sensation (see also Neurological), edema (including time of day and amount) • Change of color to the skin, especially increased pigmentation of the lower extremities, cyanosis, or any other change in color

Sexual Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Desire and ability to continue physical sexual activity • Ability to express other forms of intimacy • Changes with aging that may affect sexual functioning (e.g., vaginal dryness, erectile dysfunction)

Symptom Requirements for Delirium Diagnosis

• Disturbance in attention and awareness • Disturbance develops over a short period of time (usually a few hours to a few days) and represents a change from baseline attention and awareness • At least one additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial, perception) • Evidence that the disturbance is a direct physiological consequence of another medical condition, substance abuse, toxin exposure, or multiple conditions

Integument Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Dryness, frequency of injury, and speed of healing • Itching, history of skin cancer, sun exposure

Facilitation Strategies (Useful in Encouraging Expression of Thoughts and Feelings)

• Establish commonalities. • Share self. • Allow the person to choose subjects to discuss. • Speak as if to an equal. • Use broad openings, such as "How are you today?" • Employ appropriate use of humor. • Follow the person's lead.

Hyperactive Delirium

• Excessive alertness • Easy distractibility • Increased psychomotor activity • Hallucinations, delusions • Agitation and aggressive actions • Fast or loud speech • Wandering, nonpurposeful repetitive movement • Verbal behaviors (yelling, calling out) • Removing tubes • Attempting to get out of bed • Unpredictable fluctuations between hypoactivity and hyperactivity easier to see than hypoactive

Most Common Conditions Referred to as "Geriatric Syndromes"

• Falls and gait abnormalities • Frailty • Delirium • Urinary incontinence • Sleep disorders • Pressure ulcers

Skin Tears

•Commonly occur in those with thin, fragile skin •Classified by the Payne-Martin system •Category 1: a skin tear without tissue loss •Category 2: a skin tear with partial tissue loss •Category 3: a skin tear with complete tissue loss where the epidermal flap is absent

Predictors of Retirement Satisfaction

• Good health • Functional abilities • Adequate income • Suitable living environment • Strong social support system characterized by reciprocal relationships • Decision to retire involved choice, autonomy, adequate preparation, higher-status job before retirement • Retirement activities that offer an opportunity to feel useful, learn, grow, and enjoy oneself • Positive outlook, sense of mastery, resilience, resourcefulness • Good marital or partner relationship • Sharing similar interests to spouse/significant other

Predictors of Retirement Satisfaction

• Good health • Functional abilities • Adequate income • Suitable living environment • Strong social support system characterized by reciprocal relationships • Decision to retire involved choice, autonomy, adequate preparation, higher-status job before retirement • Retirement activities that offer an opportunity to feel useful, learn, grow, and enjoy oneself • Positive outlook, sense of mastery, resilience, resourcefulness • Good marital or partner relationship • Sharing similar interests to spouse/significant other

Factors Influencing Ability to Manage Stress

• Health and fitness • A sense of control over events • Awareness of self and others • Patience and tolerance • Resilience • Hardiness • Resourcefulness • Social support • A strong sense of self

Comprehension Strategies (Useful in Assisting With Understanding of Communication)

• Identify time confusion. (In what time frame is the person operating at the moment?) • Find the theme. (What connection is there between apparently disparate topics?) Recognize an important theme, such as fear, loss, or happiness. • Recognize the hidden meanings. (What did the person mean to say?)

Sleep Health Goals Healthy People 2020

• Increase public knowledge of how adequate sleep and treatment of sleep disorders improve health, productivity, wellness, quality of life, and safety on roads and in the workplace. • Increase the proportion of persons with symptoms of obstructive sleep apnea who seek medical evaluation. • Increase the proportion of adults who get sufficient sleep.

Healthy People 2020 Substance Abuse Objectives for Adults

• Increase the proportion of persons who need alcohol and/or illicit drug treatment and received specialty treatment for abuse or dependence in the past year. • Increase the proportion of persons who are referred for follow-up care for alcohol problems, drug problems after diagnosis, or treatment for one of these conditions in a hospital emergency department. • Increase the number of Level I and Level II trauma centers and primary care settings that implement evidence-based alcohol Screening and Brief Intervention (SBI). • Reduce the proportion of adults who drank excessively in the previous 30 days. • Reduce average alcohol consumption. • Reduce the past-year nonmedical use of prescription drugs (pain relievers, tranquilizers, stimulants, sedatives, any psychotherapeutic drug). • Decrease the number of deaths attributable to alcohol.

Principles of Person-Centered Dementia Care

• Individuals can live fully with dementia. • The quality of life for individuals living with dementia is derived not only from the care and support they receive, but also in how others perceive their value. • Being meaningfully engaged and having purpose and value as are vital to well-being as physical health. • Respect, dignity, and providing choices in daily life are foundational to person-centered care and are basic human rights.

Characteristics of Successful Chronic Illness Management Models

• Interdisciplinary team of health care professionals, often led by a nurse • Ability to conduct initial and intermittent comprehensive assessments • Skill in the development of a comprehensive care plan that is individualized, incorporates evidence-based protocols, and is culturally appropriate • Adequate funding to implement the plan over time • Actively engages the patient and family caregivers in care • Proactive monitoring of the patient's clinical status and ability and willingness to modify the care plan as needed • Success in facilitating transitions across settings • Facilitation of the patient's access to community resources

Supportive Strategies (Useful in Encouraging Continued Communication and Supporting Personhood)

• Introduce yourself, and explain why you are there. Reach out to shake hands, and note the response to touch. • If the person does not want to talk, go away and return later. Do not push or force. • Sit closely, and face the person at eye level. • Limit corrections. • Use multiple ways of communicating (gestures, touch). • Search for meaning. • Know the person's past life history as well as daily life experiences and events. • Remember there is a person behind the disease. • Recognize feelings, and respond. • Treat the person with respect and dignity. • Show interest through body posture, facial expression, nodding, and eye contact. Assume a pleasant, relaxed attitude. • Attend to vision and hearing losses. • Do not try to bring the person to the present or use reality orientation. Go to where the person is, and enjoy the conversation. • When leaving, thank the person for his or her time and attention as well as information. • Remember that the quality, not the content or quantity, of the interaction is basic to therapeutic communication.

Communicating With a Person Experiencing Delirium

• Know the person's past patterns. • Look at nonverbal signs, such as tone of voice, facial expressions, and gestures. • Speak slowly. • Be calm and patient. • Face the person and keep eye contact; get to the level of the person rather than standing over him or her. • Explain all actions. • Smile. • Use simple, familiar words. • Allow adequate time for response. • Repeat if needed. • Tell the person what you want him or her to do rather than what you do not want him or her to do. • Give one-step directions; use gestures and demonstration to augment words. • Reassure person's safety. • Keep caregivers consistent. • Assume that communication and behavior are meaningful and an attempt to tell us something or express needs. • Do not assume that the person is unable to understand or is demented.

Challenges for the Person With a Chronic Illness

• Long-term and uncertain nature of the illness • Costs associated with care including preventive and long-term personal care • Little coordination of care across the continuum • Lack of health care professionals with expertise in geriatrics and chronic care • Focus of health care system on acute and episodic care • Continued disparities in health care outcomes for vulnerable groups

Symptoms of Mild TBI

• Low-grade headache that will not dissipate • Having more trouble than usual remembering things, paying attention or concentrating, organizing daily tasks, or making decisions and solving problems • Slowness in thinking, speaking, acting, or reading • Getting lost or easily confused • Feeling tired all of the time, lack of energy or motivation • Change in sleep pattern (sleeping much longer than usual, having trouble sleeping) • Loss of balance, feeling light-headed or dizzy • Increased sensitivity to sounds, lights, distractions • Blurred vision or eyes that tire easily • Loss of sense of taste or smell • Ringing in the ears • Change in sex drive • Mood changes (feeling sad, anxious, listless, or becoming easily irritated or angry for little or no reason)

Changes in sleep with age

• More time spent in bed awake before falling asleep • Total sleep time and sleep efficiency are reduced • Awakenings are frequent, increasing after age 50 years (>30 min of wakefulness after sleep onset in >50% of older subjects) • Daytime napping • Changes in circadian rhythm (early to bed, early to rise) • Sleep is subjectively and objectively lighter (more stage 1, little stage 4, more disruptions) • Rapid eye movement (REM) sleep is short, less intense, and more evenly distributed • Frequency of abnormal breathing events is increased • Frequency of leg movements during sleep is increased

Musculoskeletal Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Pain in joints, back, or muscles • Changes in gait and sense of safety in ambulation • If stiffness is present, when it is the worst and when it is relieved by activity • If limited, effect on day-to-day life

Communicating With Individuals Experiencing Dysarthria

• Pay attention to the speaker; watch the speaker as he or she talks. • Allow more time for conversation, and conduct conversations in a quiet place. • Be honest, and let the speaker know when you have difficulty understanding. • If speech is very difficult to understand, repeat back what the person has said to make sure you understand. • Repeat the part of the message you did not understand so that the speaker does not have to repeat the entire message. • Remember that dysarthria does not affect a person's intelligence. • Check with the person for ways in which you can help, such as guessing or finishing sentences or writing.

Dental Health Goals for Older Adults

• Prevent and control oral and craniofacial diseases, conditions, and injuries, and improve access to preventive services and dental care. • Reduce the proportion of adults with untreated dental decay. • Reduce the proportion of older adults with untreated caries. • Reduce the proportion of adults who have ever had a permanent tooth extracted because of dental caries or periodontal disease. • Reduce the proportion of older adults 65 to 74 years of age who have lost all of their natural teeth. • Reduce the proportion of adults 45 to 74 years of age with moderate or severe periodontitis. • Increase the proportion of oral and pharyngeal cancers detected at the earliest stages.

Key Points in the Chronic Illness Trajectory Framework

• The majority of health problems in late life are chronic. • Chronic illness and its management often profoundly affect the lives and identities of both the individual and the family members or significant others. • The acute phase of illness management is designed to stabilize physiological processes and return to a state of stability. • Maintaining stable phases is central in the work of managing chronic illness. • Maintaining stable phases is central in the work of managing chronic illness. • A primary care nurse often has the role of coordinator of the multiple resources that may be needed to promote quality of life at any point along the trajectory.

Risk Factors for pressure ulcers

•Comorbidities •Skin changes •Nutrition changes/status •Cognition •Incontinence •Confinement •Moisture/friction/shear/sensation •Bed-bound/wheelchair bound •Surgical procedures •Confusion •Unable to move themselves

Family and Professional Support for Depression

• Provide relief from discomfort of physical illness. • Enhance physical function (i.e., regular exercise and/or activity; physical, occupational, recreational therapies). • Develop a daily activity schedule that includes pleasant activities. • Increase opportunities for socialization and enhance social support. • Provide opportunities for decision-making and the exercise of control. • Focus on spiritual renewal and rediscovery of meanings. • Reactivate latent interests, or develop new ones. • Validate depressed feelings as aiding recovery; do not try to bolster the person's mood or deny his or her despair. • Help the person become aware of the presence of depression, the nature of the symptoms, and the availability of effective treatments. • Emphasize depression as a medical, not mental, illness that must be treated like any other disorder. • Provide easy-to-use educational materials to older adults and family members, such as those available through NIMH. • Involve family in patient teaching, particularly younger family members who may have different life experiences related to depression and its treatment. • Provide an accepting atmosphere and an empathic response. • Demonstrate faith in the person's strengths. • Praise any and all efforts at recovery, no matter how small. • Assist in expressing and dealing with anger. • Do not stifle the grief process; grief cannot be hurried. • Create a hopeful environment in which self-esteem is fostered and life is meaningful.

Healthy People 2020: Mental Health and Mental Disorders (Older Adults)

• Reduce the suicide rate. • Reduce the proportion of persons who experience major depressive episodes. • Increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral. • Increase the proportion of adults with mental disorders who receive treatment. • Increase the proportion of persons with co-occurring substance abuse and mental disorders who receive treatment for both disorders. • Increase depression screening by primary care providers. • Increase the proportion of homeless adults with mental health problems who receive mental health services.

Components of an Annual Medical Exam for the Person With Parkinson's Disease

• Review of current medications • Assessment of mental health (evidence of psychosis, depression, anxiety, impulse control disorders) • Cognitive status • Evidence of autonomic dysfunction: orthostatic hypotension, constipation, urinary or fecal incontinence or urinary retention, erectile dysfunction • Sleep quality • History of falls • Outcome of rehabilitation if used • Safety issues relative to the stage of the disease • Safe use and effectiveness of current medications • Psychosocial and support needs

Common Widower Bereavement Reactions

• Search for the lost mate • Neglect of self • Inability to share grief • Loss of social contacts • Struggle to view women as other than wife • Erosion of self-confidence and sexuality • Protracted grief period

Sun Protection

• Seek the shade. • Do not burn. • Avoid indoor tanning booths and sunlamps. • Wear hats with a brim wide enough to shade face, ears, and neck, as well as clothing that adequately covers the arms, legs, and torso. Cover up with clothing, including a broad-brimmed hat and UV-blocking sunglasses. • Use a broad-spectrum (UVA/UVB) sunscreen with an SPF of 30 or higher every day. • Apply 1 ounce (2 tablespoons) of sunscreen to your entire body 30 minutes before going outdoors. Reapply every 2 hours or immediately after swimming or excessive sweating. • Examine your skin head-to-toe every month. • See your health care provider every year for a professional skin exam.

Prevention of Delirium

• Sensory enhancement (ensuring glasses, hearing aids, listening amplifiers) • Mobility enhancement (ambulating at least twice a day if possible) • Bedside presence of a family member whenever possible • Cognitive orientation and therapeutic activities (tailored to the individual) • Pain management • Cognitive stimulation (if possible, tailored to individual's interests and mental status) • Simple communication standards and approaches to prevent escalation of behaviors • Nutritional and fluid repletion enhancement • Sleep enhancement (sleep hygiene, nonpharmacological sleep protocol) • Medication review and appropriate medication management • Adequate oxygenation • Prevention of constipation • Minimize the use of invasive medical devices, restraints, or immobilizing devices • Pay attention to environmental noise, light, temperature • Normalize the environment (provide familiar items, routines, clocks, calendars) • Minimize the number of room changes and interfacility transfers

Symptoms of Moderate to Severe TBI

• Severe headache that gets worse or does not disappear • Repeated vomiting or nausea • Seizures • Inability to wake from sleep • Dilation of one or both pupils • Slurred speech • Weakness or numbness in the arms or legs • Loss of coordination • Increased confusion, restlessness, or agitation

Factors to Consider in Selecting Pressure Injury Dressing

• Shallow, dry wounds with no/minimal exudate need hydrating dressings that add or trap moisture; very shallow wounds require cover dressing only (gels/transparent adhesive dressings, thin hydrocolloid, thin polyurethane foam). • Shallow wounds with moderate to large exudate need dressings that absorb exudate, maintain moist surface, support autolysis if necrotic tissue present, protect and insulate, and protect surrounding tissue (hydrocolloids, semipermeable polyurethane foam, calcium alginates, gauze). Cover with an absorptive cover dressing. • Deep wounds with moderate to large exudate require filling of dead space, absorption of exudate, maintenance of moist environment, support of autolysis if necrotic tissue present, protection, and insulation (copolymer starch, dextranomer beads, calcium alginates, foam cavity). Cover with gauze pad, ABD, transparent thin film, or polyurethane foam.

Respiratory Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Shortness of breath and, if present, circumstances in which this occurs • Frequency of respiratory problems • Need to sleep in chair or with head elevated on pillows

Major Risk Factors for the Development of Chronic Diseases

• Smoking or exposure to second-hand smoke • Lack of exercise • High sugar and fat diet • Obesity

Personalistic (Magicoreligious) System

•Believes that supernatural entities, such as gods, deities, or nonhuman beings that include ghosts, ancestors, or spirits, cause illness •Health is viewed as a blessing or reward •Rituals, such as the "laying on of hands" and prayer circles, are performed

Assessment of Depression

• Utilize a depression screening tool (GDS or Cornell if cognitive impairment). • Assess for suicidal thoughts. • Investigate somatic complaints and look for underlying acute or chronic stressful events. • Investigate sleep patterns, changes in appetite or weight, socialization pattern, level of physical activity, and substance abuse (past and present). • Ask direct questions about psychosocial factors that may influence depression: elder abuse, poor environmental conditions, and changes in the patient role after death or disability of a spouse/partner. • Obtain psychiatric and medical histories. • Perform a physical exam including a focused neurological exam. • Complete a functional assessment (pay close attention to changes in ADL function). • Perform a cognitive assessment; depressed patients may show little effort during examination, answer "I don't know," and have inconsistent memory loss and performance during exam. • Conduct a medication review (assessment for medications that may cause depressive symptoms). • Ask about psychotic symptoms (delusions, hallucinations) and symptoms of bipolar disorder. • Perform laboratory work as appropriate to rule out other causes of symptoms (e.g., TSH, T4, serum B12, vitamin D, folate, complete blood count, urinalysis). • Utilize family/significant others in obtaining key information to correlate patient's symptoms with others' observations; always assess and interview patient first.

Medicare Part B

•A person eligible for Part A must apply for Part B in the 6 months surrounding his or her 65th birthday or wait until the next open enrollment •Special Enrollment period—if retired after age 65 and were covered by group health plan based on being employed, can sign up for anytime you are still covered by the group health plan or up to 8 months after employment ends •Not signing up for Part B at time of retirement or end of covered group health plan, will pay a penalty when you do sign up for Part B •Choose either (the "Original") Medicare Part B or an alternative plan available in his or her area •Original is a traditional fee-for-service arrangement •Patient is responsible for a monthly premium (usually deducted directly from the monthly Social Security check), an annual deductible, and co-pays

Role of Acute Illness

•Acute and chronic conditions are intricately intertwined •A previously stable chronic condition often worsens when an acute illness occurs •Example: person whose congestive heart failure has been well-managed with diet and medications has an episode of pneumonia; this triggers acute heart failure

Services provided through Medicare Part A

•Acute care—pays for up to 150 days of hospitalization in decreasing amounts •Skilled rehabilitative nursing care in a health care facility provided by licensed nurse (RN/LPN), OT, PT •Requires 72-hour in-patient hospital stay •If no skilled care needed—does not pay •Hospice care •Inpatient psychiatric care •Home health services requiring skilled care—LPN/RN, OT, PT •Must be homebound (see T & J, Box 7.4, p 83 for details)

Constipation Implications for Nurses

•Assess •Precipitants and causes of constipation •Thorough bowel history •Physical assessment rules out systemic causes •Food and fluid intake •Abdomen is examined for masses, distention, tenderness, and bowel sounds •Rectal examination is performed for painful anal disorders ASK ABOUT POOP

Cultural Skills

•Based on mutual respect •Listening carefully •Attending to both verbal and nonverbal communication •Understanding the meaning behind the "story" •Explain the nurse's perception clearly without judgment •Acknowledging differences and similarities between the nurse's perception of goals and the elder's •Develop a plan that considers both perspectives and is mutually acceptable

Naturalistic (Holistic) System

•Based on the concept of balance •Disturbances in balance result in disharmony and, subsequently, illness •Stems from civilizations of China, India, and Greece •Diagnosis requires determination of the type or extant of imbalance •Treatments are methods to restore balance and harmony

1935 Social Security Act

•Considered to be one of the most successful federal government programs •Monetary benefits to lift burden on families •Limited to U.S. citizens and legal residents •Payroll taxes paid by employer and employee •Available at a certain age regardless of income or assets •Average monthly stipend in 2016 was $2212 for couple, both receiving benefits

UI Nursing Implications

•Continence must be routinely addressed in the initial assessment of every older person •Nurses are expected to be able to collect and organize data about urine control, report findings, and implement evidence-based interventions •Continence care is a quality of care indicator for nursing homes; residents should be assessed on admission and whenever there is a change in cognition, physical ability, or urinary tract function •Incontinence can be cured in 80% of individuals

Services provided through Medicare Part B

•Covers some outpatient or ambulatory services •Covers up to 80% of cost of office visits—physician, NP, PA •Limited prescribed supplies •Medically necessary diagnostic tests •OT, PT, Speech therapy for rehab purposes •Limited durable medical equipment if prescribed by MD and documented as medically necessary •Outpatient treatment, blood work, and ambulatory surgical services •Some preventative services: Flu shot, glaucoma testing, Hepatitis B shots if at high risk, Hepatitis C screening, pneumococcal shots, kidney dialysis (NOTE: Shingles shot covered in Part D) •Diabetes supplies (not oral medications or insulins) (T & J, p 84, Box 7.6)

Pressure Injury Care

•Dressing change assessment •Wound care specialist as appropriate •Dressing selection is important!

Promotion of a healthy bladder

•Drink 8-10 glass of water before 8 pm •Reduce caffeine/alcohol •Urinate before/after meals and bed •Don't ignore the urge •Keep toilet easy to get to with lighting at night •Ideal body weight, exercise •Don't smoke •Seek help for symptoms

Xerostomia

•Dry mouth •Affects eating, swallowing, and speaking •Contributes to dental caries and periodontal disease •If medication side effects are contributing to dry mouth, medications may be changed or altered •Affected persons should practice good oral hygiene practices, regular dental care, adequate water intake, and avoid alcohol •Saliva substitutes and salivary stimulants may help

Preventing Fungal Infections

•Dry well •Change frequently •Loose fitting clothes and incontinence products •Watch for skinfolds •Optimal nutrition

Medicare Part D

•Elective prescription drug plan (PDP) with associated out-of-pocket premiums and co-payments •All persons with either Medicare Part A or Medicare Part B eligible to voluntarily purchase Medicare Part D PDP •Cost depends upon income level •Has a deductible—must meet annually before Part D coverage kicks in •Coverage gap— "Donut hole"

Bowel Elimination Interventions for Nurses

•Environmental manipulation (access to toilet) •Diet alterations •Habit-training schedules •Improved transfer and ambulation abilities •Sphincter-training exercises •Biofeedback •Medications •Surgery to correct underlying cause

Gait Disturbances

•Especially observed in those older than 85 •Are indicative of an underlying pathological condition • Some underlying pathological conditions cause neurologic damage and result in gait problems: such as arthritis, diabetes, dementia, Parkinson's disease, stroke, alcoholism, and vitamin D deficiency -effects falls

Western of Biomedical System

•Health care providers are usually consider it to be superior to all others •Disease is the result of abnormalities in the structure and function of body organs and systems caused by the invasion of germs •Treatment destroys the invading organism •Prevention involves avoiding pathogens, chemicals, activities, and dietary agents that are thought to cause abnormalities

reducing health disparities

•Increase cultural competence •Increase cultural awareness •Consideration of •Individual and community health belief paradigms •Factors such as poverty and racism •Obtain cultural knowledge •Provide culturally proficient care

Consequences of UI

•Increased risk of falls, fractures, hospitalization, and skin breakdown •Loss of dignity and autonomy •Increased feelings of depression, anxiety, shame, and embarrassment •Increased social isolation •Sexual activity is avoided •Loss of independence and self-confidence

raloxifene (Evista):

•Increases bone density in a manner similar to estrogen's action •Reduces risk for spine fractures but not other fractures •Increases risk of DVT HORMONE

Using interpreters

•Interpreter tells the older adult patient what the nurse has said and then tells the nurse what the patient has said •A translator deals with the written word •Communication needs to be respectful •Sentences should be short •Metaphors are avoided

Pressure Ulcers: A geriatric syndrome

•Localized damage to the skin or underlying soft tissue (usually occur over bony prominences or related to medical devices) •Older adults account for 70% of pressure ulcers •Prevention is considered the key to care - really hard to fix •Medicare and Medicaid reimbursement- chart! •Effect many older adults - immobility and skin changes

Assisted Living

•Long-term care setting •Housing, not a health care facility •Home environment •Greater resident autonomy •"Menu" of services including assistance with ADLs, skilled nursing care •As one of the fastest growing industries within the United States, assisted living offers privacy, independence, and security. •Services in an assisted-living facility include laundry, assistance with meals and personal care, 24-hour oversight, and housekeeping. •Some facilities provide assistance with medication administration, although nursing care services are not available directly. •The national median monthly fee is $3500 for a private unit (NCAL, 2014). With no government fee caps and little regulation, assisted living is not always an option for individuals with limited financial resources.

Preventing Skin Tears

•Move patients carefully •Protective clothing •Avoid adhesive products (paper tape) •Provide education on prevention to patients and staff

Medicare Part C

•Offers Medicare Advantage Plans similar to an HMO or PPO •Privately managed care plans •Replaces both Medicare Part A and Medicare Part B •Co-pays and deductibles, if any, vary considerably, and extra premiums may be required for added services •Several new programs alternatives to Medicare Part C, such as Private Fee-For-Service Medical Savings Accounts

Medicare Part A

•Offers acute care or short-term rehabilitative care •(T & J, Box 7.4, p. 83) •Free to those who receive Social Security (no premium) •Provides insurance regardless of financial status •A person is automatically enrolled on the first of the month of his or her 65th birthday •if the person applied for Social security •Deductible and co-payments under Part A vary by setting and can be quite high

Interventions for Fall Intervention

•One-size-fits-all approach does not work •Interventions depend on the person's changing condition •Type, timing, and frequency of the interventions are tailored to the person •Education about fall prevention is an important intervention for patients, families, and the community

Pressure Ulcers Implications for Gerontological Nursing and Healthy Aging

•Perform skin assessment •Identify risk factors •Recommend and implement preventive interventions and treatments •Evaluate! •Provide education to patients and families •Don't forget about nutrition

Medicaid

•Program funded jointly by federal government and state government •State determines eligibility, types, and extent of services to be covered; sets the payment rates to providers; and administers its own programs •States pay about 40% of the costs with the federal government paying the rest •Covers more services than Medicare •Provides health services for low-income children, pregnant women, those who are permanently disabled, and persons age 65 and older •Majority of funds are used to provide long-term nursing care for older and disabled adults

Nursing Centers

•Provide 24-hour intermediate and custodial care •Nursing, rehabilitation, diet, social, recreational, and religious services •Residents of any age with chronic or debilitating illness •A nursing center is a resident's temporary or permanent home, with surroundings made as homelike as possible. •Nursing facilities succeed when they recognize residents as active participants and decision makers in their care and life in institutional settings. •Staff must complete the Resident Assessment Instrument (RAI) on all residents. The RAI consists of the Minimum Dataset (MDS), Resident Assessment Protocols, and utilization guidelines of each state. The collected information provides a national database for nursing facilities so policy makers will better understand the health care needs of the long-term care population. The MDS is a rich resource for nurses in determining the best interventions to support the health care needs of this growing population.

Supplemental security income (SSI)

•Provides stipends to low income people who are aged 65 years or older, blind, or disabled •Social Security income is not adequate

Assessment of spiritual concerns

•Spiritual history •Patients may need permission •Rituals are important •Simply listen

Transient (acute) UI

•Sudden onset •Present for 6 months or less •Usually caused by treatable factors such as urinary tract infections (UTIs) or delirium

Established (chronic) UI

•Sudden or gradual onset •Includes stress; urge; urge, mixed, or stress UI with high postvoid residual (PVR); functional UI; and mixed UI

fecal incontinence

•The involuntary loss of liquid or solid stool that is a social and hygienic problem •Often associated with UI •Can be transient or persistent •Devastating social affects •Contributing factors include damage to the pelvic floor, neurologic disorder, functional impairment, immobility, and dementia Accidental Bowel Leakage

Culture

•The shared and learned values, beliefs, expectations, and behaviors of a group of people •Guides thinking, decision making, and beliefs about aging, health and health seeking, illness, treatment, and prevention •Cultural values extend into the delivery health care any time the "seeker" and "giver" meet

Medicare

•To be eligible for Medicare, one must be eligible for Social Security •Only covers select services and requires that they are medically necessary •Costs are covered by a employer and employee tax of 2.9% and by the beneficiary in the form of premiums, deductibles, and co-pays •A program of the federal government

Catheter-Associated Urinary Tract Infections (CAUTI's)

•UTIs that occur in a patient with an indwelling catheter or within 48 hours of catheter removal •Most common hospital-acquired infection worldwide •Incidence decreased by implementing evidence-based guidelines, catheter reminders, stop orders, nurse-initiated removal protocols, and a urinary catheter bundle

Care for Veterans

•Veterans Administration (VA) system is a model for the continuity of care in various care provider systems •Active duty and retired military members and their dependents are eligible •VA hospitals have restrictions; the problem has to be service related

Nutrition Implications for Gerontological Nursing

▪Comprehensive nutritional screening and assessment are essential in identifying older adults at risk for nutrition problems or who are malnourished ▪The role of nursing assessment and intervention should be comprehensive and include -Increased attention to the process of eating and the entire ritual of meals -Assessment of nutritional status -Thorough medication review

Nutrition Screening Tools

▪Nutrition Screening Initiative Checklist ▪Mini Nutritional Assessment (MNA) -Both a screening tool and a detailed assessment -Only valid for those older than age 65 years -Intended for use by professionals ▪Minimum Data Set (MDS) ▪Food and nutrient intake -24-Hour dietary recall -3-Day dietary history

Nurses Role: Losses

◦Assess nature of psychosocial and adaptations to changes ◦Communication: Explore strengths, coping skills, goals and desires ◦Coping methods ◦Hobbies and activities ◦Assess/explore: Is this person showing signs of depression?

2 categories of vulnerability under MN law

◦Categorical: based mostly on where someone lives (nursing home, assisted living) ◦Functional: based on level of dependency on others

Intimacy and chronic illness

◦Chronic illnesses and their related treatments may bring many challenges ◦Individuals want and need information ◦Providers need to become more knowledgeable and more actively involved

Who is most likely to be abused?

◦Confused ◦Dependent ◦Frail ◦Had abused in past or been abused ◦Alone ◦Women ◦Institution ◦"Hard" behavior ◦Feel they deserve it

Diagnosing Osteoporosis

◦Diagnosed by dual-energy x-ray absorptiometry (DEXA) ◦Presumed to be present in older adults with: 1. nontraumatic fractures 2. a loss of 3+ inches in height 3. kyphosis

Nursing roles include

◦Helping older patients deal with financial issues ◦Using their expert advocacy and negotiation skills

Erectile dysfunction (ED)

◦Inability to achieve and sustain an erection sufficient for satisfactory sexual intercourse ◦Multiple causes exist for this problem ◦Use of phosphodiesterase inhibitors has revolutionized treatment for ED (ED meds can't be used if pt has cardiac issues)

Sexuality and Dementia

◦Intimacy and sexuality remain important in the lives of persons with dementia and their partners Issues ◦Consent when cognitively impaired ◦Inappropriate sexual behavior ◦Sexual inappropriateness

Types of Loss

◦Loss of cognitive processes, mental capacity ◦Health ◦Mobility ◦Self-management ◦Financial resources & security ◦Loss of independence ◦Retirement and reduced income ◦Psychosocial ◦Touch ◦Housing

Caring for patients with dementia

◦Maintain function and prevent excess disability ◦Structure the environment and relationships to maintain stability ◦Compensate for the losses associated with the disease ◦Create a therapeutic milieu

Multiples Losses

◦More than one loss at a time ◦Multiple health problems, chronic illnesses ◦Add relocation, death of spouse or partner

Osteoporosis Pathophysiology

◦Normal: osteoblasts add bone tissue = osteoclasts break down bone tissue ◦Osteoporosis: Imbalance between osteoclast and osteoblast activity ◦Certain bones more likely to be affected: hip, long bone of the leg, wrist, vertebrae and pelvis

Who are included as part of a vulnerable population?

◦Older adults ◦People living in poverty ◦People who are homeless ◦Immigrant populations ◦People in abusive relationships ◦People with substance abuse ◦Those with severe mental illnesses ◦Children

Nurses responsibility in regards to sexuality and STDs

◦Provide an opportunity for discussion ◦Be an educator ◦Know one's feelings about sexuality

Ziminski, Phillips, & Woods article

◦Purpose of study: Describe injury presentations in emergency department of people > 65 years old with and without cognitive impairment ◦Explore the relationship of injury presentations to injury etiology (cause) among those with and without cognitive impairment ◦Main points: ◦It's important to understand & recognize common injuries in older adults so than uncommon injuries, such as those from abuse, can be identified. ◦Implications for nurses: ◦Recognize that accidents and injuries are important reasons for older adults to come to emergency departments (ED) for care

Sexuality in Long-Term Care Facilities

◦Sexual needs of older adults in long-term care facilities should be addressed with the same priority as nutrition, hydration, and other needs Issues ◦Attitudes of staff, family ◦Privacy

Sexuality of Older Adults

◦Sexuality allows a general affirmation of life ◦Various spheres

Losses of the Elderly

◦The longer people live, the more changes and losses they experience ◦Several losses may occur at the same time ◦Effect: High risk for illness and functional deterioration

Nurses are Mandated Reporters of Abuse & Neglect

◦This is the intersection of nursing and the law. We don't need to be lawyers to be nurses, but we need to understand our legal responsibilities to our patients. ◦Never judge; there are many factors involved in abuse & neglect