Week 1: Chapter 3 (Older adult) / Chapter8 (Rehab)/ ATI Books

Nurse is assessing an older adult client's alcohol use. Which client statement warrants a follow-up collection of more data? "I am a 'tea-totaller'; I never drink anything alcoholic." "I had three (3) glasses of champagne at my granddaughter's wedding last month." "I like to have a glass of wine every once in awhile." "I usually drink two (2) vodkas to help me get to sleep each night."

*D* More routine is important

An RN is arriving for night duty at an acute care hospital. Which of these clients does the RN assess first? A. A 65-year-old who is scheduled for surgery the next day B. A 68-year-old who has chronic protein-calorie malnutrition C. A 70-year-old who has a history of gout and is complaining of joint pain D. A 72-year-old who was admitted to the unit with postoperative delirium Rationale

*D. Malnutrition does not indicate any acute risk for complications. is an acute state of confusion*

A nurse is teaching a class of unlicensed assistive personnel (UAP) about turning and repositioning clients in a long-term care setting. Which client requires extreme caution and is at greatest risk for a skin tear? A. 38-year-old client with paraplegia resulting from a motor vehicle accident B.70-year-old client with a recent total hip replacement receiving rehabilitation care C. 80-year-old client with a recent stroke and left-sided paralysis D. 85-year-old client with breathing problems receiving daily doses of prednisone

*D. Skin tears are also common in older adults, especially the old-old group and those who are on chronic steroid therapy.*

Managed care organizations (MCOs) -

- Primary care providers oversee comprehensive care for enrolled clients and focus on prevention and health promotion.

State licensing boards:

- to ensure that health care providers and agencies comply with state regulations

› The Joint Commission (formerly JCAHO) -

- to set quality standards for accreditation of health care facilities

Private plans

-Traditional insurance reimburses for services on a fee-for-service basis. » Managed care organizations (MCOs) - » Preferred provider organizations (PPOs) - » Exclusive provider organizations (EPOs) - » Long-term care insurance

Rehab patients typically receive care for

1 to 3 weeks

While outdoors, wear protective clothing, use sunscreen, and avoid sun exposure between

10-4

To reduce drug-related risks in older adults, perform a medication assessment every

6 months or more often if an acute illness or exacerbation of a chronic disease occurs

Dementia

A slowly progressive cognitive decline, also called chronic confusion

Breast cancer screening

Ages 20 to 40, clinical breast examination every 3 years, then annually; ages 50 to 74, mammogram every 2 years

Cervical cancer screening

Ages 21 to 29, Papanicolaou test (Pap smear) every 3 years; ages 30 to 65, Pap and human papilloma virus test every 5 years

How often should older adults get sunlight?

Allow at least 10 to 15 minutes of sun exposure two or three times weekly for vitamin D intake; avoid prolonged sun exposure.

What helps relocation stress?

Allow pt to assist in decision making. Explain all procedures and routines. Reorient pt of location Encourage family to visit often/ or to accompany pt when leaving unit. Avoid room changes

Body mass index (BMI)

At each routine health care visit

Clinical testicular examination

At each routine health care visit starting at age 20

Blood pressure

At least every 2 years, annually if previously elevated

What collaborative interventions will be most helpful to promote cognitive health?

C. Joining a peer group with a common learning goal D. Learning a new skill F. Starting a new physical activity

What questionnarie is for older adults for alcohol abuse?

CAGE Do you drink to take your mind off your problems? When you feel lonely, does having a drink help? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to settle your nerves to get rid of a hangover (eye-opener)?

Preferred provider organizations (PPOs) -

Clients choose from a list of contracted providers. Using noncontracted providers increases the out-of-pocket costs.

Exclusive provider organizations (EPOs) -

Clients choose from a list of providers within a contracted organization.

Are severe cognitive changes part of the normal aging process? What are they?

Cognitive impairment, depression, hallucinations, and delusions are not part of the normal aging process.

Rehabilitation nurses in the inpatient setting do what?

Coordinate/Collaborates the efforts of health care team members and function as the patient's case manager. Nurses also create a rehabilitation milieu and discharge care

The client's daughter gives the nurse a long list of drugs that the client is taking at home, both prescription and over-the-counter. What does the nurse do first and second?

Copying the list to the assessment should be done first. Then, the health care provider should be notified of all the drugs, which may or may not be ordered during the client's stay, depending on the client's diagnosis.

Older changes to the cognitive:

Decreased reaction time to stimuli and an impairment of memory for recent events

Regulatory agencies that address health:

Evaluates respiratory status and provides respiratory treatments including oxygen therapy, chest physiotherapy, inhalation therapy, and mechanical ventilation. ◯ Example of when to refer - A client who has respiratory disease is short of breath and requests a nebulizer treatment.

Respiratory Therapist

Evaluates respiratory status and provides respiratory treatments including oxygen therapy, chest physiotherapy, inhalation therapy, and mechanical ventilation. ◯ Example of when to refer - A client who has respiratory disease is short of breath and requests a nebulizer treatment.

Dental assessments

Every 6 months

How often should older adults exercise

Exercise regularly three to five times a week.

The biggest concern regarding accidents among older adults in both the community and inpatient setting is

Falls

Older adults who are homebound, focus on what kind of exercise?

Functional fitness, such as performing ADLs.

What happens when a older adult limits their fluid intake?

It makes them susceptible to dehydration and electrolyte imbalances (especially sodium and potassium) that can cause serious illness or death. Incontinence may actually increase because the urine becomes more concentrated and irritating to the bladder and urinary sphincter.

Ways to increase sleeping at night and decrease insomnia?

Keep patients awake during the day by increasing activities. Keep room dark as possible. Postpone treatments until waking hours or early morning if they can be delayed safely. If possible, place a "Do not Disturb" sign on the patient's door to avoid unnecessary interruptions in sleep

Older need a ____ dose than younger adults?

Lower

How should older adults take care of their mind?

Manage stress through coping mechanisms that have been successful in the past. • Get together with people in different settings to socialize. Reminisce about your life through reflective discussions or journaling.

Public federally funded programs:

Medicare Medicaid

Is confusion a normal part of the aging process?

NO

65 years or older should have how many alcohol it drinks a day/week?

No more than one alcoholic drink a day or seven drinks in a week

two health problems experienced by older adults:

Nutrition and mobility

What do Occupational THERAPIST do?

Occupational therapists work to develop the patient's fine motor skills used for ADL self-management, such as those required for eating, hygiene, and dressing. OTs also teach patients how to perform independent living skills, such as cooking and shopping.

Regarding airway Older adults are more prone to

Older adults are prone to aspiration of oral secretions because of decreased cough and gag reflexes

Changes in older adults nutrition

Older adults need an increased dietary intake of calcium, vitamin D, vitamin C, and vitamin A because aging changes disrupt the ability to store, use, and absorb these substances. A sedentary lifestyle and reduced metabolic rate require a reduction in total caloric intake to maintain an ideal body weight. Older adults most prone to: protein-calorie malnutrition

Another fact contributing to older adult loss of desire to food?

Other than diminished taste poor dental status can affect their ability to chew.

What helps older adults cope with crisis?

People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crisis.

What do physical therapists do?

Physical therapists intervene to help the patient achieve self-management by focusing on gross mobility skills (e.g., by facilitating ambulation and teaching the patient to use a walker) (Fig. 8-1). They may also teach techniques for performing certain ADLs, such as transferring (e.g., moving into and out of bed), ambulating, and toileting, and can assist with cognitive retraining (often for patients with TBI)

Incontinence is common in older adults but it is not a what? What staff members helps with this activity?

Physiologic change of aging, but it is very common in both the hospital and long-term care setting. Place the patient on a toileting schedule or a bowel or bladder training program, if appropriate. Delegate and supervise this activity to unlicensed assistive personnel.

How does drugs effect the older adult?

Physiologic changes of aging predispose older adults to toxic effects of medication; drugs are absorbed, metabolized, and distributed more slowly. They are also excreted more slowly by the kidneys.

Radiologic Technologist

Positions clients and performs x-rays and other imaging procedures for providers to review for diagnosis of disorders of various body parts. ◯ Example of when to refer - A client reports severe pain in his hip after a fall, and the provider prescribes an x-ray of the client's hip.

How to decrease the incidence of delirium and prevent falls.

Promote sleep and rest for older adults

Nurse administrator -

Provides leadership to nursing departments within a health care facility.

Other factors that contribute to inadequate nutrition among older adults?

Reduced income Chronic disease Fatigue Decreased ability to perform ADLs Loneliness Being hospitalized before starting home health care, having a primary care provider who is not a female family member, and having a low level of education

Factors that contribute to inadequate nutrition among older adults.

Reduced income, chronic disease, fatigue, and decreased ability to perform activities of daily living

Older adults who are NOT homebound, focus on what kind of exercise?

Resistance exercise, for example, maintains muscle mass. Aerobic exercise, like walking, improves strength and endurance. One of the best exercises is walking at least 30 minutes, three to five times a week. The person may walk for 30 continuous minutes or walk 3 times a day for 10 minutes.

Older adults have diminished?

Senses of taste and smell often result in a loss of desire for food. Older adults have less ability to taste sweet and salt than to taste bitter and sour.

Fulmer SPICES six serious markers

Sleep disorders. Problems with eating of feeding. Incontinence. Confusion. Evidence of falls. Skin breakdown

Blood cholesterol

Starting at age 20, a minimum of every 5 years

Blood glucose

Starting at age 45, a minimum of every 3 years

Prostate-specific antigen test, digital rectal examination

Starting at age 50 if indicated

Colorectal screening

Starting at age 50, high-sensitivity fecal occult blood testing every year, or flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years

How can stress affect the older adult?

Stress can speed up the aging process over time, or it can lead to diseases that increase the rate of degeneration. It can also impair the reserve capacity of older adults and lessen their ability to respond and adapt to changes in their environment.

Assessment tool for screening for medication-related risks in older adults?

The Beers Criteria The tool lists multiple medications and related concerns.

Abuse of an older adult is most likely the

The abuser is often a family member who becomes frustrated or distraught over the burden of caring for the older adult.

Who is the lead of the care team?

The nurse

Long-term care insurance -

This provides for long-term care expenses Medicare does not cover.

To help prevent and manage delirium do what?

Use a calm voice to frequently reorient the patient, soothing music may have a calming effect. Providing a doll or stuffed animal to "fidget" with may prevent the patient from removing important medical tubes or equipment. If the patient has a favorite item, such as an afghan blanket or a picture, ask the family or significant others to provide it for the same purpose.

Routine physical examination

Variable, generally every 3 to 5 years from age 20 to 40, more often after 40

Social workers do what?

Works with clients and families by coordinating inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and discharge. ◯ Example of when to refer - A client who has terminal cancer wishes to go home but is no longer able to perform many activities of daily living. The spouse needs medical equipment in the home to care for the client.

A person is not legally competent means

a guardian is appointed to make financial and health care decisions

A physician who specializes in rehabilitative medicine is called a

a physiatrist.

Continuing health care

addresses long-term or chronic health care needs. Examples include end-of-life care, palliative care, hospice, adult day care, and in-home respite care.

Primary prevention

addresses the needs of healthy clients to promote health and prevent disease with specific protections. -Immunization programs › Child car seat education › Nutrition, fitness activities › Health education in schools

When should you use restraints for older adults

after all alternatives have been tried. Last resort

Tertiary prevention

aims to prevent the long- term consequences of a chronic illness or disability and to support optimal functioning. -Prevention of pressure ulcers after spinal cord injury › Promoting independence after traumatic brain injury

Vocational counselors do what?

assist with job placement, training, or further education. Work-related skills are taught if the patient needs to change careers because of the disability. Licensed practical nurses.

The primary cause of falls

decreased mobility in old age.

Primary health care

emphasizes health promotion, and includes prenatal and well-baby care, nutrition counseling, and disease control. This level of care is a sustained partnership between clients and providers. Examples include office or clinic visits and scheduled school- or work-centered screenings (vision, hearing, obesity).

Preventive health care

focuses on educating and equipping clients to reduce and control risk factors for disease. Examples include programs that promote immunization, stress management, and seat belt use.

Secondary prevention

focuses on identifying illness, providing treatment, and conducting activities that help prevent a worsening health status. -Communicable disease screening, case finding › Early detection, treatment of diabetes mellitus › Exercise programs for older adults who are frail

The most common settings for care are

freestanding rehabilitation hospitals, rehabilitation units within hospitals, and skilled nursing facilities.

Secondary health care

includes the diagnosis and treatment of acute illness and injury. Examples include care in hospital settings (inpatient and emergency departments), diagnostic centers, and emergent care centers.

Restorative health care

involves intermediate follow-up care for restoring health. Examples include home health care, rehabilitation centers, and skilled nursing facilities.

Tertiary health care

involves the provision of specialized and highly technical care. Examples include intensive care, oncology centers, and burn centers.

Delirium

is an acute state of confusion. Delirium differs from dementia in that it is usually short-term and reversible, often occurring in unfamiliar settings.

Medicare

is for clients 65 years of age or older and for those with permanent disabilities.

Medicaid

is for clients with low incomes. - It is federally funded. - Individual states determine eligibility requirements.

A clinically competent person

is legally competent and capable of making clinical decisions

Depression

mood disorder that have cognitive, affective, and physical manifestations. The most common underdiagnosed and underrated mental health disorder among older adults

Patients with chronic and disabling health problems often participate in rehabilitation programs to

prevent further disability, maintain functional ability, and restore as much function as possible.

a woman who is sexually active before the age of 20 should start screenings when

sexual activity begins

Rehabilitation is

the process of learning to live with chronic and disabling conditions.

Regulatory agencies help ensure

the quality and quantity of health care and the protection of health care consumers.

Health care finance influences

the quality and type of care by setting parameters for cost containment and reimbursement.

geriatric failure to thrive:

thrive—a complex syndrome including under-nutrition, impaired physical functioning, depression, and cognitive impairment.

Utilization review committees -

to monitor for appropriate diagnosis and treatment of hospitalized clients

How often should older adults have a physical exam?

yearly

A person is legally competent if he or she is:

•18 years of age or older •Pregnant or a married minor •A legally emancipated (free) minor who is self-supporting •Not declared incompetent by a court of law

Common health issues of the older adult include:

•Decreased nutrition and hydration •Decreased mobility •Stress and loss •Accidents •Drug use and misuse •Mental health/behavioral health problems (including substance abuse) Risk for dehydration because they have less body water content than younger adult Decreased reaction time Decreased the awareness of body orientation Decreased sense of touch Decrease in liver size, a decrease in liver blood flow, and a decrease in serum liver enzyme activity. Decreased renal blood flow and reduced glomerular filtration rate Increased ratio of adipose tissue to lean body mass, a decreased albumin level Decreased cardiac output.

Evidence-based interventions for skin breakdown:

•Nutritional support •Avoidance of skin injury from friction or shearing forces •Repositioning and support surfaces every 8 hours for reddened areas that do not blanch. •A plan to increase mobility and activity level, when appropriate •Skin cleansing and use of moisture barriers and avoid briefs or absorbent pads that can cause skin irritation and excess moisture

Physical changes related to older adults Part 1:

■ A decrease in skin turgor, subcutaneous fat, and connective tissue (dermis), which leads to wrinkles and dry, transparent skin ■ A loss of subcutaneous fat, which makes it more difficult for older adults to adjust to cold temperatures ■ Thinning and graying of the hair, as well as a more sparse distribution ■ Thickening of the fingernails and toenails ■ A decrease in chest wall movement, vital capacity, and cilia, which increases the risk for respiratory infections ■ A slower reaction time ■ A decrease in touch, smell, and taste sensations ■ A decrease in the production of saliva ■ A decline in visual acuity ■ A decrease in the ability for the eyes to adjust from light to dark leading to night blindness, which is especially dangerous when driving