121 Module 6

How to communicate with patients with hearing loss

-Face them -Minimize distractions -Speak distinctly (don't yell) -Use gestures and expressions that reinforce your message -Use written materials and assistive devices -Encourage patient to verbalize -Check patient's hearing device -Use ASL interpreter if needed

Five functional syndromes associated with aging to look out for when caring for older adults

-Falls -Urinary incontinence -Pressure ulcers -Functional decline -Delirium

Tips for communicating with patients who have dementia (Table 17.1)

-Face the patient -Gain their attention before speaking -Use non verbal active listening skills -Use brief sentences (short and sweet) -Speak clearly, slightly slower -Use more nonverbal cues -Observe patient for nonverbal cues -Use positive reinforcement -Use photos when patient asks about someone -Verify patient understanding

Receptive aphasia

-Difficulty receiving and processing written and oral messages -Affects your ability to read and understand speech. You can hear what people say or see words on a page, but you have trouble making sense of what they mean

Early signs of dementia

-Difficulty remembering appointments -Difficulty remembering names -Using the wrong word, jumbling words -Not following conversations -Difficulty recalling timing of events -Difficulty remembering all the steps for a task -Difficulty planning -More labile mood -Buying things they already have -Loss of interest in activities

Communication DON'TS with dementia patients

-Don't argue -Don't confront -Don't use slang/jargon -Don't focus on difficult behavior -Don't restrain -Avoid choking hazards

Strategies for communicating with patients with treatment-related communication deficits

-Encourage them to display pictures or objects from home -Orient them to environment, time, and place -Ask questions (esp. yes/no) -Frequently provide info -Reassure them -Give explanations -Make communication assistive devices available -Have them validate understanding

Understand Treatment-Related communication deficits (pg 343-344)

-Encourage them to display pictures or objects from home -Orient them to environment, time, and place -Ask questions (esp. yes/no) -Frequently provide info -Reassure them -Give explanations -Make communication assistive devices available -Have them validate understanding

Review Tips for Communicating With Patients Who Have Dementia (Table 17.1 pg 337)

-Face the patient -Gain their attention before speaking -Use non verbal active listening skills -Use brief sentences (short and sweet) -Speak clearly, slightly slower -Use more nonverbal cues -Observe patient for nonverbal cues -Use positive reinforcement -Use photos when patient asks about someone -Verify patient understanding

How to communicate with patients with mental-processing deficits (e.g. difficulty with visual or auditory processing)

-Adapt messages to understandable level -Keep trying to connect -Listen carefully/actively

Understand how to best address Catastrophic Reactions (pg 381-382)

-Address whatever is causing the frustration -Look out for warning signs (agitation, stiffening, refusals, uncooperative) -Distract -Postpone frustrating task -Use gentle, calm verbal/nonverbal -Don't argue

Three barriers older adults face in getting medical treatment

-Ageism -Navigating the medical system -Decreasing number of health care providers accepting Medicare

Review Symptoms of Dementia with Suggested Behavioral Communication (Table 19.2, pg 383-384)

-Agitation -Aggression -Withdrawal -Refusal/resistance -Disturbed motor activity (wandering, pacing, etc) -Sleep disturbance -Hallucinations/delusions

Ways to facilitate successful aging in older adults (communication strategies)

-Allow reminiscence and sharing of stories -Access to elder care services -Encourage exercise programs and other activities -Short, frequent conversations -Acknowledgment -Focus on what the patient considers important

Functional consequences theory

-An older adult's quality of life correlates with his/her functional capacity and capacity to meet personal dependency needs -Focuses on the needs that are unique to older individuals -This framework helps nurses assess patients across a continuum of functioning, from high functioning to frail older adults -Emphasizes interventions, which emphasize functional self-management -holistic perspective of mind, spirit, and body inter-relatedness

What factors can affect patient responses to care situation

-Anxiety and fear -Pain -Too much/little stimuli -Sleep deprivation -Physiological needs (e.g. hunger, thirst) -Losing track of time -Too much change -Multiple care providers -Immobility -Don't understand information

Things to include when assessing pain

-COLDSPA -Quality and nature of pain -When it occurs and under what circumstances -How it affects their functioning -Where it occurs (e.g. deep, superficial, localized, radiating) -Contributing factors

Expressive aphasia

-Difficulty expressing language -you know what you want to say, but you have trouble saying or writing your thoughts

How to communicate with patients with vision loss

-Get the attention of the patient -Orient patient to the environment -Compensate for nonverbal aspect of message -Use touch effectively -Allow patient to hold your arm when walking -Utilize low-vision resources -Orient patient to environmental hazards -Clean patient's glasses if necessary -Keep environment free of hazards

Types of communication deficits

-Hearing loss -Vision loss -Impaired verbal ability (e.g. aphasia) -Impaired cognitive processing -Mental disorders -Environmental deprivation

Review Lack of communication due to lowered level of consciousness (pg 343)

-Hearing may remain acute, even if they don't respond -Treat them with dignity -Still call them by name; orient to time, place, location; explain procedures; use therapeutic touch

Mini Cognition Exam

-If you notice signs of cognitive changes -Three words - have them repeat immediately -Have them draw a clock face, and set the time -Have them repeat the three words again -Ask about memory concerns

Speech disorder

-Impaired articulation of speech -person has problems creating or forming speech sounds

Language disorder

-Impaired comprehension or use of spoken sounds -interferes with learning, understanding, and using language

Interventions for older patients to support successful aging

-Life review -Reminiscence groups -Social support -Supporting independence -Safety support -Medication support (for managing polypharmacy) -Advocacy

Considerations for dementia patients

-May need to defuse catastrophic reaction -Sundowning -Legal issues (e.g. ability to provide consent) -Need to advocate for them

How might a patient respond to new hearing loss (pg 335)

-May try to hide it -Withdraw from relationships -Become depressed -Less likely to seek info from health care providers

Communication DOS with dementia patients

-Minimize stimuli -Look at them directly -Identify emotions behind behavior -Minimize anxiety -Use calm nonverbal cues -Repeat messages if needed -Give directions one step at a time -Use soft music -If their attention lapses, let them rest before trying to regain their attention

Review the behaviors of sundowning (pg 382)

-More agitated behaviors later in the day -Fretfulness -Anxiety -Demanding -Days and nights reversed

Signs of cognitive changes in older adults

-Require more time to complete verbal tasks and process unfamiliar information -Trouble with digital communication -More cautious, hesitation (esp. under pressure) -More likely over 85 years old

How to communicate with cognitively impaired older adults (cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life)

-Supporting adaptation to daily life -Supporting communication -Touch -Reality orientation -Validation therapy

How to communicate with patients that exhibit a lack of communication due to lowered level of consciousness (e.g. coma)

-Treat as though the patient can understand -Orient patient frequently -Provide familiar objects -Explain noises, procedures, and equipment -Encourage family to interact -Utilize technologies to enhance communication

Four pillars of caring for a dementia patient

-Treating the disease -Treating the symptoms -Supporting the patient -Supporting the caregiver

Review adaptive communication strategies for vision loss (pg 370)

-Use adaptive devices -Make sure their prescription gets updated -Assist them around steps, curbs, uneven terrain -Eliminate tripping hazards (e.g. throw rugs) -Verbally note environmental hazards -Face patient when speaking -Verbally explain all written info -Bright lighting, no glaree -Use large fonts -Encourage audio books, etc.

How to communicate with patients with impaired verbal communication secondary to speech/language deficits (inability to receive, relay, or process language) (e.g. stroke, language barriers)

-Use communication tools (e.g. picture board) -Speak slowly with simple sentences -Allow extra time for processing and for replying -Address one topic/question at a time -Encourage communication efforts -Use technology appropriately -Use referrals as needed

The nurse is performing an admission assessment on a client with cognitive impairment. When developing a plan of care for this client, the nurse should plan to a. Provide instructions one step at a time. b. Offer several instructions at a time when orienting the client to their room. c. Teach the client new skills using complex instructions with multiple steps. d. Refrain from mentioning the client's past life experiences when asking questions.

ANS: A Cognitively impaired clients have trouble following instructions consisting of multiple steps. Breaking instructions into single steps helps these clients master tasks that otherwise are beyond their comprehension. Keep the conversation simple and focused on one step at a time. Asking mild to early moderate cognitively impaired older adults about their past life experiences is a way to connect verbally with those who might have difficulty telling you what they had for breakfast 2 hours ago. Remote memory (recall of past events) is retained longer than memory for recent events. When cognitively impaired adults share memories, they are giving a gift to the nurse by sharing part of themselves when they may have very little else to give.

The nurse is caring for an older adult client who has recently experienced losses associated with deaths of important people in her life. The nurse recognizes that this type of problem challenges which of Maslow's hierarchy of needs? a. Physiological integrity b. Love and belonging c. Self-actualization d. Safety and security

ANS B: Maslow's hierarchy of needs helps nurses prioritize nursing actions, beginning with basic survival needs. Physiological integrity, followed by safety and security, emerge as the most basic critical issues for aging adults, and need to be addressed first. Love and belonging needs are challenged by increased losses associated with death of important people. Esteem needs, especially those associated with meaningful purpose, and independence remain important issues in later life. Abraham Maslow believed that self-actualization occurs more often in middle aged and older adults. Love and belonging needs are challenged by increased losses associated with death of important people. Esteem needs, especially those associated with meaningful purpose, and independence remain important issues in later life. Abraham Maslow believed that self-actualization occurs more often in middle-aged and older adults.

When communicating with older adult clients, the nurse recognizes that a. Hearing problems can diminish an older person's ability to interact with others. b. Hearing loss associated with normal aging begins after age 40 years. c. Older adults who experience hearing loss initially cannot hear lower frequency sounds of vowels. d. Older adults distinguish sounds better against background noises.

ANS: A Hearing problems can diminish an older person's ability to interact with others, attend concerts and other social functions, and understand medical directions. Hearing loss associated with normal aging begins after age 50 due to loss of hair cells (which are not replaced) in the organ of Corti in the inner ear. This change leads initially to a loss in the ability to hear high-frequency sounds (e.g., f, s, th, sh, ch) and is called presbycusis. Lower Frequency sounds of vowels are preserved longer. Older adults have special difficulty in distinguishing sounds against background noises and in understanding fast-paced speech.

A client diagnosed with dementia is becoming increasingly unable to express complete thoughts and is having difficulty engaging in simple conversations. When communicating with this client, the nurse should a. Use words directly applicable to the client's daily routine. b. Restate ideas using different words in a different sequence. c. Refrain from validating the meaning of the client's responses. d. Ask the client questions that require more than a yes or no answer.

ANS: A Instead of using abstract prompts (like a specific time), the nurse should use words directly applicable to the client's daily routine, like before lunch, to anchor the client's recognition of time frames. The nurse should restate ideas using the same words and sequence and validate the meaning of a client's response. As dementia progresses, clients become increasingly unable to express complete thoughts and eventually cannot carry on even simple conversations. The nurse should use questions that can be answered with a yes or no for clients with less verbal skill. The nurse should note whether the client's behavior is consistent with the yes or no answer and follow up if the behavior is incongruent with the words.

The nurse is caring for an older adult patient who is recovering from a stroke. When the nurse speaks to the patient, the patient nods and responds using incoherent words. Which type of aphasia does this patient exhibit? a. Expressive b. Receptive c. Global d. Cognitive

ANS: A The patient with expressive aphasia can understand what is being said but cannot express thoughts or feelings in words. Receptive aphasia creates difficulties in receiving and processing written and oral messages. With global aphasia, the patient has difficulty with both expressive language and reception of messages. A patient may have feelings of loss and social isolation imposed by the communication impairment. While there may be no cognitive Impairment, the patient may need more think time for cognitive processing during a conversation.

A patient with which diagnosis will most benefit from the use of touch during a therapeutic encounter? a. Vision-impairment b. Moderate hearing loss c. Mentally illness d. Schizophrenia

ANS: A The social isolation experienced by blind patients can be profound, and the need for human contact is important. Touching the patient lightly as the nurse speaks alerts the patient to the nurse's presence. For vision-impaired patients, the nurse should let the person know when Approaching by a simple touch, and always indicate when leaving. The nurse should use touch and close physical proximity while with the patient and give the patient something substantial to touch when leaving the patient. The nurse should tap on the floor or table to get the patient's attention via vibration. Other communication problems occur with different mental disorders. As an example, some patients with mental disorders can have intact sensory channels, but they cannot process and respond appropriately to what they hear, see, smell, or touch. In some forms of schizophrenia, there are alterations in the biochemical neurotransmitters in the brain that normally conduct messages between nerve cells and help orchestrate the person's response to the external environment. Messages have distorted meanings. While the remaining options present needs, touch is most therapeutic to the visually impaired patient.

The nurse is caring for a patient who has experienced a stroke resulting in aphasia. What type of deficit should the nurse assess for? a. Neurological linguistic b. Cognitive comprehension c. Sensory deprivation d. Social withdrawal

ANS: A When the ability to process and express language is disrupted, many areas of functioning are assaulted simultaneously. Aphasia is a neurological linguistic deficit, such as occurs after a stroke. Aphasia can present as primarily an expressive or receptive disorder. The person with expressive aphasia can hear and understand what is being said but cannot express thoughts or feelings in words.

An Older client has an order for a new medication. When preparing to administer the medication to the client for the first time, the nurse gets ready to educate the client and the client's daughter about the medication. When educating the client and the daughter, the nurse should do all of the following except a. Observe the client before implementing teaching and gear teaching strategies to meet the individual needs of the client. b. Direct instructions to the client's daughter. c. Draw on the client's experiences and interests in planning teaching. d. Make the teaching session short enough to avoid tiring the client.

ANS: B Assuming that cognitive intact older adults lack the capacity to understand instructions is a common error. Health care providers often direct instruction to the older adult client's younger companion, even when the client has no cognitive impairment. This action invalidates the client and diminishes self-worth. Simple modifications to reduce age-related barriers to learning when teaching older adults include: • Explain why the information is important to the client. • Use familiar words and examples in providing information. • Draw on the client's experiences and interests in planning teaching. • Make teaching sessions short enough to avoid tiring the client, and frequent enough for continuous learning support. • Speak slowly, naturally, and clearly. Health teaching for the elderly is critical if they are to master the tasks of old age and maintain their health. Healthy older adult learning capabilities remain intact, although older adults may need more time to think about how they want to handle a situation. The sensitive nurse observes the client before implementing teaching and gears teaching strategies to meet the individual learning needs of each client. Four aspects of successful aging—fall prevention, adequate nutrition, socialization, and medication management—lend themselves to health teaching formats.

Which statement is true concerning communication deficits? a. Communication deficits occur primarily because of physical disabilities. b. Communication deficits can arise from sensory deprivation. c. Individuals who are equally impaired are equally disabled. d. The primary nursing goal is to minimize the patient's independence.

ANS: B Communication deficits can arise from the kind of sensory deprivation that occurs in some agencies and units such as intensive care units. A communication disability definition includes any patient who has any impairment in body structure or function that interferes with communication. Specifically, the patient has a communication difficulty due to impaired functioning of one or more of his five senses or he has impaired cognitive processing functioning. Communication deficits can arise from the kind of sensory deprivation that occurs in some agencies and units such as intensive care units. Two individuals can have the same sensory impairment but not be equally communication disabled. Each person compensates for their impairment in different ways. The primary nursing goal is to maximize the patient's ability to successfully interact with the health care system.

The nurse is caring for an older adult patient who has recently withdrawn from relationships, appears depressed, and appears reluctant to seek information from the nurse due to a hearing loss. What assessment should the nurse focus on to help minimize additional dysfunction? a. Willingness to seek help when needed. b. Tendency to hide hearing related deficits c. Alterations to personal conversational style. d. Impairment related to consonant discrimination.

ANS: B Deprived of a primary means of receiving signals from the environment, patients with hearing loss may try to hide deficits, may withdraw from relationships, and become depressed. While the other options are appropriate assessments, they are not as focused on minimizing additional social and physical dysfunctions related to a hearing loss.

An older adult client tells the nurse, My life has been a waste. The nurse recognizes this statement as demonstrating which aspect of psychosocial development? a. Ego integrity b. Ego despair c. Lack of generativity d. Isolation

ANS: B Erikson's (1982) model of psychosocial development is used to describe older adult psychosocial development. His is one of the only developmental models that specifically addresses later adulthood (> 60 years) as a stage of ego development. Erikson portrays the maturational crisis of old age as that of ego integrity versus ego despair. Awareness of one's personal mortality leads to the psychosocial crisis identified with this last stage of ego development. Ego despair describes the failure of a person to accept one's life as appropriate and meaningful. Left unresolved, despair leads to feelings of emotional desolation and bitterness. Ego integrity relates to the capacity of older adults to look back on their lives with satisfaction and few regrets, coupled with a willingness to let the next generation carry on their legacy. Lack of generativity and isolation are not stages found in the older adult client.

When caring for a hearing-impaired patient, the nurse should implement what intervention to facilitate communication? a. Face the interpreter when speaking to the patient. b. Use gestures that reinforce verbal content. c. Speak distinctly while exaggerating words. d. Communicate in a dimly-lit room.

ANS: B For hearing-impaired patients, the nurse should use facial expressions and gestures that reinforce verbal content. The nurse should always face the patient when communicating, so the patient can see the nurse's lips move. The nurse should speak distinctly without Exaggerating words. Partially deaf patients respond best to well-articulated words spoken in a moderate, even tone. The nurse should stand or sit to face the patient and allow the patient to see facial expressions and mouthing of words. The nurse should also communicate in a Well-lighted room so there is no impairment of vision for the patient.

The nurse is caring for an older adult client. The nurse recognizes that the factor most closely associated with the older adult's inability to live independently is a. Chronological age. b. Functional status. c. Relationship needs. d. Social functioning.

ANS: B More than any other factor, impaired functional status is a determinant of an older adult's inability to live independently. Stress, acute and chronic illness, and age-related physiologic changes will influence a person's functional status. Functional status, rather than chronological age, should be the stronger indicator of disability-related needs in older adults because functional impairment is not associated solely with age.

The nurse while providing bedside care for an unconscious patient, is overheard stating, I wouldn't want to live in this condition. What did this nurse not realize about the patient's capabilities? a. The patient has the right to respect regardless of condition. b. Hearing can remain acute in patients who are not fully alert. c. The nurse has a duty to act as the patient's advocate. d. The standard of care has not been met with regards to this nurse's actions.

ANS: B When a patient is not fully alert, it is not uncommon for nurses to speak in their presence in ways they would not if they thought the patient could fully understand what is being said, forgetting that hearing can remain acute. Good clinical practice suggests never saying anything the nurse would not want the patient to hear. While the other options are true statements, they are not related to the patient's capabilities.

When caring for the patient with macular degeneration, the nurse facilitates communication by implementing which action? a. Facing the patient directly. b. Standing to the patient's side. c. Speak distinctly while exaggerating words. d. Refrain from touching the patient.

ANS: B When caring for patients with macular degeneration, the nurse should remember to stand to their side, an exception to the face them directly rule applied with hearing loss patients. Macular degeneration patients often still have some peripheral vision. The nurse should use touch and close physical proximity while with the patient, and the nurse should give the patient something substantial to touch when leaving the patient.

When caring for a nonverbal patient, the nurse should implement what intervention to maintain communication? a. Insisting the patient communicate in a two-way mode. b. Continuing to initiate communication in a one-way mode. c. Refraining from explaining procedures to avoid stressing the patient. d. Limiting orienting cues in order to reduce environmental stimuli.

ANS: B When patients are unable or unwilling to engage in a dialogue, the nurse should continue to initiate communication in a one-way mode. Giving orienting cues is recommended, such as labeling of meals as breakfast, lunch, or dinner; and linking events to routines (e.g., saying, The x-ray technician will take your chest x-ray right after lunch) helps secure the patient in time and space.

Review Sorting Out the Three D's: Delirium, Dementia, Depression (Table 19.1, pg 378)

Delirium - acute, reversible Dementia - chronic, irreversible Depression - >2 weeks, reversible

When assessing an older adult client, the nurse notes that the client demonstrates an inability to take purposeful action even when the muscles, senses, and vocabulary appear to be intact. The client appears to register on a command but acts in a way that suggests little understanding of what transpired verbally. The nurse recognizes these assessment findings as consistent with which of the following conditions? a. Presbycusis b. Somatization c. Apraxia d. Polypharmacy

ANS: C Apraxia, defined as the loss of the ability to take purposeful action even when the muscles, senses, and vocabulary seem intact, is a common feature of dementia. The person appears to register on a command but acts in ways that suggest he or she has little understanding of what transpired verbally. Hearing loss associated with normal aging begins after age 50 years and is due to loss of hair cells (which are not replaced) in the organ of Corti in the inner ear. This change leads initially to a loss in the ability to hear high-frequency sounds (e.g., f, s, th, sh, ch) and is called presbycusis. Although most people weather the necessary losses of life, late life depression is an often untreated problem in older adults. Unlike symptoms of depression in younger people, somatization with vague physical complaints may be its first presenting sign. Polypharmacy is a fact of life for older adults. As people age, many need multiple medications to maintain a healthy lifestyle. Polypharmacy places older adults at risk for side effects and drug interactions because of age-related changes in metabolism. Medications in general have a stronger effect on the older population and take longer to be eliminated from the body.

The nurse is caring for a patient who is hearing-impaired and legally blind in the right eye and has just returned from cataract surgery on the left eye. The nurse recognizes that what statement is relevant to the patient's safety when being ambulated? a. The patient's arm should be held when walking to provide direction. b. Verbal speech is ineffective in this situation and should not be relied upon by the staff. c. Signals should be developed to indicate changes in pace or direction while walking. d. The patient should be discouraged from dependence on reading lips especially while ambulating.

ANS: C For vision-impaired patients, the nurse should develop and use signals to indicate changes in pace or direction while walking. The nurse should not lead or hold the patient's arm when walking, but instead allow the patient to take the nurse's arm. The nurse should speak distinctly without exaggerating words. Partially deaf patients respond best to well-articulated Words spoken in a moderate, even tone. The patient with hearing loss should be encouraged to verbalize speech, even if they only use a few words or the words are difficult to understand at first. The nurse should always face the patient when communicating so the patient can see the nurse's lips move.

The nurse is caring for a patient who has experienced global aphasia secondary to a stroke. Which intervention is most appropriate for this patient? a. Refraining from exploiting any language skills that are preserved. b. Frequently reminding the patient they cannot be understood. c. Encouraging short, positive sessions that focus on communication. d. Spending long periods of time talking with the patient to provide stimulation.

ANS: C Patients who lose both expressive and receptive communication abilities have global aphasia. These patients can become frustrated when they are not understood. Struggling to speak causes fatigue. Short, positive sessions are used to communicate. Otherwise, the patient may become nonverbal as a way of regaining energy and composure. Any language skills that are preserved should be exploited.

The nurse is caring for a frail older adult client who is admitted to the hospital after falling. The client has been living alone independently and appears reluctant to accept assistance. The nurse recognizes that the client's reluctance to accept assistance is most likely caused by fear of a. Inability to pay for services. b. Additional financial burden on the family. c. Relinquishing independent living. d. Loss of privacy.

ANS: C The nurse may need to directly observe environmental supports, bearing in mind that a potential association exists in the older adult's mind between accepting help and relinquishing independent living.

The nurse is caring for an older adult client who has been diagnosed with dementia. The nurse recognizes which of the following as true in relation to the use of touch with this client? a. Clients with dementia can ask for touch. b. Clients with dementia can create touch for themselves. c. Clients with dementia can become more anchored in the present time, space, and humanity when touched. d. Clients with dementia can tell the nurse about the meaning of touch.

ANS: C Touch is something clients with dementia can no longer ask for, create for themselves, or tell another of its meaning. Touch is a form of communication, used to reinforce simple verbal instructions with cognitively impaired adults and as a primary form of communication. It is experienced not only physically as sensation, but also effectively as emotion and behavior. As dementia progresses, gentle touch can anchor an anxious or disoriented person in present time, space, and humanity. When used to gain a client's attention or to guide a person toward an activity, touch can acknowledge a client's stress, calm an agitated client, or provide a sense of security. In general, clients with dementia appreciate the use of touch.

When assessing an older adult client, the nurse recognizes the client has a significant hearing loss. The most appropriate intervention by the nurse is to a. Introduce herself first. b. Shout into the client's good ear. c. Repeat words the client doesn't understand. d. Check the hearing aid batteries.

ANS: D Adaptive strategies for hearing loss include helping older adults adjust hearing aids. Older adults lack fine-motor dexterity and may not be able to insert aids correctly to amplify hearing. The nurse should make sure hearing aids are turned on. If difficulties persist, the nurse should check the batteries. Adaptive strategies for hearing loss also include addressing the person by name before beginning to speak (it focuses attention) and speaking slowly and distinctly. If the nurse's voice is high pitched, the nurse should lower it and rephrase rather than repeat words if the older adult doesn't understand certain words.

The Three D's

Delirium, Dementia, Depression

The nurse has just completed a care plan on a visually impaired client. Which of the following interventions is most appropriate for this client? a. Stand away from the client when communicating to not obstruct the view of the immediate environment. b. Provide the client with reading material that has all capital letters. c. Verbally explain all written information while discouraging the client from asking questions. d. Ensure the client's room has bright lighting with no glare.

ANS: D Adaptive strategies for vision loss include providing bright lighting with no glare, having the nurse stand in front of the client, and considering the font and letter size for readability when using written materials. Upper and lower case letters rather than all capitals should be used. Solid paper with sharp, contrasting writing and a lot of white space should also be used. Adaptive strategies for vision loss also include verbally explaining all written information while allowing time for the client to ask questions.

The nurse understands that as patients age, they are more likely to have vision problems that may interfere with the communication process, including the lens of the eyes becoming less flexible, making it difficult to accommodate shifts from far to near vision. The nurse recognizes that this condition is known by what term? a. Receptive aphasia. b. Autism. c. Presbycusis. d. Presbyopia.

ANS: D As patients age, they are more likely to have vision problems that may interfere with the communication process because the lens of the eyes become less flexible, making it difficult to accommodate shifts from far to near vision. This is a condition known as presbyopia. Receptive aphasia creates difficulties in receiving and processing written and oral messages. Atypical communication is often the first behavioral clue to cognitive impairment in young children, associated with conditions such as mental retardation, autism, and affective disorders. Presbycusis, or degeneration of ear structures, is a sensorineural dysfunction that normally occurs as one ages.

When attempting to communicate a procedure to a hearing-impaired patient, what strategy would not facilitate client understanding? a. Speaking distinctly but without exaggerating words. b. Attempting to use sign language. c. Using an assisted listening device. d. Explaining complex terms last.

ANS: D Even when a patient appears not to understand, the nurse should explain in very simple terms what is happening. Assisted listening devices are among many tools recommended for communicating with hearing-impaired patients. For these patients, the nurse should speak distinctly without exaggerating words. American Sign Language has been a standard communication tool for many years, however, few care providers were able to use it.

When caring for an older adult client who is experiencing memory loss, the nurse notes that the client emotionally overreacts to situations, appearing as if having temper tantrums when responding to real or perceived frustration. The nurse recognizes the client is experiencing a catastrophic reaction. When caring for this client, the nurse should a. Attempt to keep the client awake for extended periods of time. b. Demand the client stop demonstrating inappropriate behavior. c. Increase the client's environmental stimuli. d. Use distraction to move the client away from the offending environmental stimuli.

ANS: D Instead of focusing on the behavior, the nurse should try to identify and eliminate the cause(s). The nurse should use distraction to move older adults away from the offending stimuli in the environment or use postponement. Older adults with memory loss lack the cognitive ability to develop alternatives. They emotionally overreact to situations and can have what look like temper tantrums in response to real or perceived frustration. Older adult tantrums are called catastrophic reactions and represent a completely disorganized set of responses. Usually there is something in the immediate environment that precipitates the reaction. Fatigue, multiple demands, overstimulation, misinterpretations, or an inability to meet expectations are contributing factors.

When visiting a client in his or her home, the home health nurse notes that the client frequently shifts the conversation to reminisce. Which of the following communication techniques would be most effective for the nurse to use with this client? a. Restating b. Changing the subject c. Providing information d. Asking about the client's life history

ANS: D Older adults appreciate having the nurse provide structure to the history-taking interview by explaining the reasons for it and what it will involve. Asking clients to share something about themselves and their life history, apart from the reasons for the health visitor admission, helps to establish rapport and increases the client's comfort level. By relating their life stories and exploring options relevant to their current health situation, older adults are able to step back and look at their situation in the present from a broader perspective. Nurses get to know the client as a person rather than categorically as an older adult. Ego integrity relates to the capacity of older adults to look back on their lives with satisfaction and few regrets, coupled with a willingness to let the next generation carry on their legacy. Integrity involves acceptance of one's one and only life cycle as something that had to be and that by necessity permitted of no substitution. Acceptance develops through self-reflection and dialogue with others about the meaning of one's life. Nursing strategies encouraging life review and reminiscence groups facilitate the process. Old age is shaped by a lifetime of experience. Assessment of older adult clients begins with their story. As they relate their story, the nurse should look for value-laden psychosocial issues (e.g., independence, fears about being a burden, role changes, and vulnerability) and client preferences. These are significant issues for older adult clients that may not be directly expressed.

When communicating with a patient diagnosed with a serious mental disorder, it is important for the nurse to recognize which fact about these patients? a. They seldom have intact sensory channels. b. Those with a flat affect are easier to understand. c. Such patients are typically very talkative. d. Social isolation is commonly demonstrated.

ANS: D Patients with serious mental disorders may have a different type of communication deficit resulting from a malfunctioning of the neurotransmitters that normally transmit and make sense out of messages in the brain. Social isolation and impaired coping may accompany the patient's inability to receive or express language signals. Other communication problems occur with different mental disorders. As an example, some patients with mental disorders can perhaps have intact sensory channels, but they cannot process and respond appropriately to what they hear, see, smell, or touch. The nurse may notice a lack of vocal inflection and an unchanging facial expression. A flat affect makes it difficult to truly understand the patient. Some patients with mental disorders present with a poverty of speech and limited content. Speech appears blocked; reflection disturbed patterns of perception, thought, emotions, and motivation.

The nurse is caring for an older adult client who has early moderate cognitive impairment and has been diagnosed with dementia. When interacting with the client's family, the nurse should teach family members that a. Memory for recent events is retained longer than remote memory. b. It is important to focus on recent events when asking the client questions. c. Reminiscing about the past can cause the client undue distress. d. Reminiscing about the past can be a means of connecting.

ANS: D Remote memory (recall of past events) is retained longer than memory for recent events. Family members can be encouraged to reminisce with dementia clients. This can be a meaningful experience for the family member, even when the client cannot actively engage in the discussion, because it is a means of connecting. It is not uncommon for a dementia client to show through facial expression or garbled words that he/she too experiences the connection, even if only for a fleeting moment. Or it may come later. Asking mild to early moderate cognitively impaired older adults about their past life experiences serves as a way to connect verbally with those who might have difficulty telling you what they had for breakfast 2 hours ago.

When performing a mental status examination on an older adult client, the nurse discovers that the client is illiterate and only has a third-grade education. How should the nurse assess the client's cognition? a. Have the client spell the word world backwards. b. Have the client spell the word world forwards. c. Ask the client to perform serial 7s. d. Instruct the client to state the days of the week backwards.

ANS: D The nurse should determine the client's level of formal education. If the client never learned to spell, it will be impossible to spell world backwards. Saying the days of the week backwards is a good alternative. Spelling and use of serial 7s would not be an appropriate alternative with this client's level of formal education.

What is mental competence or decisional capacity in legal terms?

Ability of a person to manage their personal legal affairs

What is considered successful aging?

Ability to adapt flexibly to age-related changes without relinquishing central components of self-definition

What are the characteristics of delirium?

Acute (hours, days); relieved with treatment of cause; severity fluctuates; short attention span; disoriented to time and place but not person; recent and immediate memory impaired; incoherent thinking; speech may be incoherent, disorganized; can be caused by toxicity, fever, tumor, infection, drugs

Global aphasia

Difficulty expressing language and receiving messages

What are the characteristics of depression?

Can have a rapid onset; may coincide with losses; can resolve with treatment; lasts at least 2 weeks; decreased motivation; difficulty concentrating; quiet irritable, negative thinking; disturbed sleep pattern

Dementia

Characterized by working memory loss, loss, particularly for recent events, significant personality changes, and a progressive deterioration in intellectual functioning

Review Communication DO's and Don'ts With Dementia Patients (Box 19.9, pg 380)

DON'Ts -Don't argue -Don't confront -Don't use slang/jargon -Don't focus on difficult behavior -Don't restrain -Avoid choking hazards DOs -Minimize stimuli -Look at them directly -Identify emotions behind behavior -Minimize anxiety -Use calm nonverbal cues -Repeat messages if needed -Give directions one step at a time -Use soft music -If their attention lapses, let them rest before trying to regain their attention

Presbycusis

Degeneration of ear structures; occurs with aging

Ageism

Discrimination based on age

How to communicate with someone who is hallucinating or experiencing delusions

Don't challenge their statements or enter into a prolonged discussion of illogical thinking; maybe identify the underlying theme they are trying to convey without validating the delusion

What is the main way nurses can support patients with ego integrity in old age?

Listen to them reflect on their life

Apraxia

Loss of the ability to take purposeful action even when the muscles, senses, and vocabulary seem intact; loss of ability to execute or carry out skilled movement and gestures, despite having the physical ability and desire to perform them; common feature of dementia

Communication deficit

Impairment in the ability to receive, send, process, and comprehend concepts of verbal, nonverbal, and graphic symbol systems

What are the characteristics of dementia?

Progresses gradually over months/years; irreversible; progressive deterioration; may be affected by sundowning; attention span usually unaffected; impaired memory for immediate/recent events; repetitive speech; associated with age, cardiovascular deficits, substance dependence

How can you assess pain in nonverbal patients?

Observing behavior, expressions (e.g. grimacing, tightened muscles, growning, agitation, lethargy, unwillingness to move)

How can social isolation affect pain?

Older adults who are socially isolated or depressed can experience greater pain than those who remain connected with a social support system

Why are there more old people now vs. 100 years ago?

People live longer; many diseases are no longer fatal

Validation therapy (for dementia patients)

Rather than confronting dementia patients with facts—that people they knew or places they have lived are no longer available to them—focus on the personal meaning events and people hold for the patient.

Legal considerations with dementia patients

The time to execute legal documents to patient rights is before patients become unable to cognitively assign decision-making authority to someone they trust. Patients in the early stages of dementia usually have sufficient mental competence to participate in legal decisions regarding their health care and finances. The criterion is that the patient has to understand what he or she is signing.

Six areas of essential functioning (ADLs)

Toileting, feeding, dressing, grooming, bathing, ambulation

Three cohorts of older adults (by age)

Young-old (65-74 years) Old-old (75-84 years) Oldest-old (85 years and older)

Erikson's model - ego integrity

acceptance of one's one and only life cycle as something that had to be and that by necessity permitted of no substitutions; Nurses can help frame the older adult's illness story with recognition of social supports and patterns of psychosocial responses in ways that help them reflect on the personal meaning of life. Nursing strategies encouraging life review and reminiscence groups facilitate the process.

Sundowning

agitated behavioral symptoms, usually occurring later in the day with dementia patients; sleep may be disturbed

Practical wisdom

emphasizes good judgment and the capacity to resolve complex human problems in the real world

Transcendent wisdom

focuses on existential concerns and self-knowledge, which allows a person to transcend subjectivity, bias, and self-centeredness in relation to an issue

Aphasia

impairment of language, either speaking or understanding

Erikson's model - ego despair

the failure of a person to accept one's life as appropriate and meaningful. Left unresolved, despair leads to feelings of emotional desolation and bitterness