WGU study guide for care of the older adult OA

Top five racial groups in United States

European Americans, African Americans, Hispanic Americans, Asian Americans, and Native Americans

Identify the two most widely publicized components of health promotion

Exercise and nutrition

Describe the Framingham Heart Study. What did it look at and what were the findings

A 50-year, longitudinal study of over 5,000 subjects designed to identify factors that cause and prevent cardiovascular disease. As a result of decades of epidemiologic work, the following risk factors have been identified: • • Age greater than or equal to 50 for men and 60 for women • • Hypertension • • Smoking • • Obesity • • Family history of premature CHD • • Diabetes (considered to be a CHD risk-equivalent, i.e., carries the same risk of a coronary event as known CHD) • • Sedentary lifestyle • • Abnormal lipid levels • The risk factors included in the Framingham calculation of 10-year risk are age, total cholesterol, HDL cholesterol, systolic blood pressure, treatment for hypertension, and cigarette smoking.

What is the definition of a fall? And what can happen to an older adult after a fall? What are the risks for falls? (Past history of falls is a major risk factor!)

A fall is defined as "an event which results in a person unintentionally coming to rest on the ground or another lower level; not as a result of a major intrinsic event (such as a stroke) or overwhelming hazard". Falls can result in injury, loss of independence, reduced quality of life, and death in the elderly. Fractures are the most serious health consequence of falls. Of those who fall, 20-30% suffer moderate to severe injuries such as hip fractures or hip traumas. Eighty-seven percent of all fractures among older adults are due to falls. The most common fractures are of the vertebrae, hip, forearm, leg, ankle, pelvis, upper arm, and hand.

What is the one of the most common role changes faced by the aging person? List all.

Retirement is perhaps one of the most common role changes faced by the aging person. Loss of a spouse causes a profound role change, with numerous transitions. The transition from health to illness involves changes in lifestyle, self-concept, and perhaps a lost sense of value and relationships. divorce can force a change in roles.

Hearing aids are one of the most common and economical devices used by a person with hearing deficits. Consider the types that would best suit the older adult

BTE (Behind the ear) - worn behind the outer ear. Has an adjustable volume and is battery powered. IT IS THE MOST COMMON. Suitable for the entire range of hearing loss. OTE (over the ear) - very small and sits on top of the outer ear. ITE (in the ear) - custom fitted, adjustable volume and battery powered. Much smaller and some may have difficulty using. Used for mild to moderate hearing loss. ITC (in the canal) - tiny that fit in the ear canal and barely visible. Customized fit. May be too small for some to use. CIC (completely in canal) - smallest type. Difficulty handling and positioning the device. Most expensive.

Explain what Medicaid is, what it covers and who is eligible

Financed by state and federal governments, administered by state. Health insurance for low income families and people with disabilities. Long term care(LTC) for older Americans and persons with disabilities. Supplemental coverage for low income Medicare beneficiaries for services not covered by Medicare.

Identify the barriers to physical activity for the older adult.

Functional decline in the elderly is attributable, at least in part, to physical inactivity. lack of access to safe areas to exercise, pain, fatigue, and impairment in sensory function and mobility.

ways to communicate or assist patient with disabilities such as hearing deficits, vision impairments, or aphasia and dysarthria.

Hearing deficits - Do not shout. Project voice from diaphragm (deepens voice). Make use of other unimpaired senses. (examples - 1)use touch or by using a visual cue and wait for patient to visually orient to you before speaking, 2)stand in front of person in a well lit room (helps the patient lip read), 3) speak to side that has better hearing, 4) make sure hearing aid is in and turned on, 5) use gestures or objects for communication. Limit background noise. Allow adequate time for response. Use short sentences and speak clearly May need to write or use a pictogram grid Vision impairments - Position yourself within their vision field. Give verbal indication of the actions you are about to do (avoid startling or scaring them). Label objects or simplify what is in their visual field. Aphasia/Dysarthria (speech impairments) - May be more anxious or self aware. Limit distractions Face patient and maintain eye contact May need to use multiple forms of communication (body language, written or pictorial information) Use short uncomplicated sentences with simple choices. Summarize message for accuracy. Take time and do not correct every error and respect the elder's limitations. Be patient!!

The most common drugs that alter lab results

Isoniazid, levodopa, morphine, vitamin C, and penicillin G may lead to false-positive urine glucose results. Levodopa may produce an increase in serum bilirubin and uric acid

Briefly discuss assistive robots and sensor-based monitoring systems that we may see used in the future and why they may be useful.

One project explores the effectiveness of a robotic reminder, which follows people around, so they cannot become lost. Professional caregivers can use the robot to establish a "tele-presence" and interact directly with remote care recipients. This makes many doctor visits unnecessary. Robots can be used for a wide range of emergency conditions that can be avoided with systematic data collection (e.g., certain types of heart failures). A semi-intelligent mobile manipulator integrates robotic strength with a person's senses and intellect. This mobile manipulation can overcome barriers in handling objects (e.g., refrigerator, laundry, and microwave) that currently force older adults to move into assisted-living facilities. Sensor-Based Monitoring-developed and is testing technological solutions for in-home distance monitoring of the functional abilities of older adults. The system is composed of unobtrusive and low-cost sensors (no cameras or microphones) that detect movement and pressure. There is a data logging and communications module, in addition to an integrated data management system, linked to the Internet. Using the appropriate data analysis tools, important observations about activities of daily living can be made from the data generated by the monitored person.

What is the risk for a sedentary life style?

Osteoporosis, heart disease, chronic disease, gross and fine motor movements are affected, obesity, stroke, HTN, MI, colorectal cancer, atherosclerosis in genital blood vessels,

Analyze a given policy or legislative act that promotes or hinders the independence and autonomy of older adults.

Patient Protection and Affordable Care Act - eliminates lifetime limits for health insurance coverage for essential services, eliminates the ability of insurance companies to rescind coverage, free preventative care, development of a prevention and public health fund, increases access to affordable care, and quality improvement and risk reduction.

Describe some of the preventive care services covered under Medicare.

One-Time "Welcome to Medicare Physical" within 6 months of initial enrollment; no deductible or copayment. Physician takes history of modifiable risk factors (coverage makes special mention of depression, functional ability, home safety, falls risk, hearing, vision), height and weight, blood pressure, EKG. Cardiovascular screening Every 5 years; no deductible or copayment;Ratio between total cholesterol and HDL, triglycerides. Cervical cancer Covered every 2 years; no deductible, copayment applies.Pap smear and pelvic exam. Colorectal cancer Covered annually for fecal occult blood test; no deductible or copayment. Covered every 4 years for sigmoidoscopy or barium enema; deductible and copayment apply. Covered every 10 years for colonoscopy; deductible and copayment apply. Densitometry Covered every 2 years; deductible and copayment apply. Diabetes screening Annually, those with prediabetes every 6 months; no deductible or copayment. Not covered routinely, but includes most people age 65+ (if overweight, family history, fasting glucose of 100-125 mg/dl [prediabetes], hypertension, dyslipidemia). Mammogram Covered annually; no deductible, copayment applies. Prostate cancer Covered annually; no deductible or copayment. Digital rectal examination and PSA test. Smoking Cessation Two quit attempts annually, each consisting of up to four counseling sessions. Limited to those with tobacco-related diseases (heart disease, cancer, stroke) or drug regimens that are adversely affected by smoking (insulin, hypertension, seizure, blood clots, depression). Clinicians are encouraged to become credentialed in smoking cessation. Immunization No deductible or copayment. Influenza vaccination covered annually; pneumococcal vaccination covered one time, revaccination after 5 years dependent on risk. Other Coverage Diabetes outpatient self-management training (blood glucose monitors, test strips, lancets; nutrition and exercise education; self-management skills: 9 hours of group training, plus 1 hour of individual training). Medical nutrition therapy for persons with diabetes or a renal disease: 3 hours of individual training first year, 2 hours subsequent years. Glaucoma screening annually for those with diabetes, family history, or African American descent. Persons with cardiovascular disease may be eligible for comprehensive prevention programs by Drs. Dean Ornish and Herbert Benson: coverage 36 sessions within 18 weeks, possible extension to 72 sessions within 36 weeks. Frequency and Duration These are estimates of what researchers recommend, relying most heavily on the U.S. Preventive Services Task Force recommendations, but not exclusively on them. Blood pressure: Begin early adulthood, annually, ending around age 80. Cholesterol: Begin early adulthood, every 2-3 years, ending around age 80. Colorectal cancer: Begin age 50, every 5-10 years for colonoscopy, ending around age 80. Mammogram: Begin age 40, every year or two; begin age 50 annually; begin age 65 every 2 years; ending around age 80. Osteoporosis: Begin early adulthood for women (no frequency recommended); every 2-3 years after age 65 for women, less frequently for men. Pap test: Begin with female sexual activity, two normal consecutive annual screenings, followed by every 3 years; two normal consecutive annual screenings around age 65, then discontinue. Prostate cancer: Do not do routinely, except if there is a family history or African American heritage.

Consider client related risk factors and identify changes of aging that can make the patient at risk

Risk factors for falls can be categorized into intrinsic and extrinsic factors. Intrinsic risk factors relate to the changes associated with aging and with disorders of physical functions needed to maintain balance. These functions include vestibular, proprioceptive, and visual function, as well as cognition and musculoskeletal function. Elderly persons who fall in institutions are usually more physically and/or cognitively impaired, and therefore intrinsic factors contribute most to falls and fall-related injuries. Extrinsic risk factors are related to environmental hazards and challenges such as poor lighting, stairs, clutter, and throw rugs. Extrinsic factors are implicated in up to 50% of all falls in the elderly in community settings. In institutionalized patients, the use of restraints and bed rails may increase the risk of falls because patients attempt to free themselves from these constraints.

Identify ways to promote healthy living among the elderly

Social interactions, proper nutrition, and physical activity have been found to help maintain healthy behaviors and thus promote optimal aging.

What is the Borg Category Rating Scale?

Strength (defined as the ability to exert force) is less of a predictor of positive outcomes than muscle power (defined as the ability to exert force quickly). Allows persons to rate their own level of exercise and target their desired level of activity.

Identify the three types of prevention and provide an explanation and example of each.

Senior Services of Seattle/King County began the Senior Wellness Project (later renamed Project Enhance) in 1997 at the North Shore Senior Center in Bothell, Washington. It was a research-based health promotion program that included a component of chronic care self-management that was modeled after Kate Lorig's program. Project Enhance is currently divided into two components: Enhance Fitness and Enhance Wellness. Enhance Fitness is an exercise program that focuses on stretching, flexibility, balance, low impact aerobics, and strength training. Certified instructors have undergone special training in fitness for older adults. Classes last an hour, involve 10 to 25 people, and participants can track their progress through a series of functional evaluations. Participants who completed 6 months of Enhance Fitness improved significantly in a variety of physical and social functioning measures, as well as reporting reduced levels of pain and depression. There was also a reduction in health care costs Dr. Dean Ornish, a physician at the University of California at San Francisco and founder of the Preventive Medicine Research Institute, has developed a program for reversing heart disease that has been replicated at several sites around the country. Dr. Ornish (1992) has recommended a vegetarian diet with fat intake of 10% or less of total calories, moderate aerobic exercise at least three times a week, yoga and meditation an hour a day, group support sessions, and smoking cessation. Dr. Ornish and his colleagues have reported that as a result of their program, blockages in arteries have decreased in size, and blood flow has improved in as many as 82% of their heart patients Dr. Herbert Benson is a physician affiliated with Harvard Medical School, and best known for his best-selling books on the relaxation response and for popularizing the term mind/body medicine. For individuals feeling the negative effects of stress, Benson's program teaches them to elicit the relaxation response, a western version of meditation. The Benson-Henry Institute for Mind/Body Medicine's clinical programs treat patients with a combination of relaxation response techniques, proper nutrition and exercise, and the reframing of negative thinking patterns. The Strong for Life program is a home-based exercise program for disabled and nondisabled older adults. It focuses on strength and balance, and provides an exercise video, a trainer's manual, and a user's guide. The program was designed by physical therapists for home use by older adults, and relies on elastic resistive bands for strengthening muscles. The exercise program led to a high rate of exercise adherence among older participants, as well as increased lower extremity strength, improvements in tandem gait, and a reduction in physical disability.

Age related changes which may affect therapeutic communication

Visual acuity Hearing loss Speech and language difficulties

Tobacco use is a common habit among older adults. In addition, there is also a prevalence of alcohol use and abuse. Be aware of the recommended approaches for tobacco cessation and alcoholism identification and prevention

Willing to quit smoking- use the "5 A's" ask if they are smoking, advise them to quit, assess their willingness, then assist in an attempt to quit (counseling and pharmacotherapy) and arrange for follow up contact to prevent relapse. Not willing to quit smoking - - brief intervention to promote the motivation to quit by use the "5 R's" - Relevance, risks, rewards, roadblocks, repetition. Relevance (why quitting would personally relevant to him/her); Risks (patient to identify them); Rewards (patient to set up reward system) Roadblocks (patient to identify them) Repetition (repeat with each clinic visit) SMOKING CESSATION MEDS - Chantix, Zyban, Nicotine patch, Nicotine gum, Nicotine lozenge, Nictorol Inhaler, Nicotrol NS Alcoholism treatment - Identify ones that require treatment, determine one's readiness to discuss treatment; assess one's need for detox; plan for post detox treatment in coordination with other professionals. Assessment of elderly for alcohol abuse - cognitive decline, nonadherence with appointments, psychiatric history, insomnia, poorly controlled HTN, frequent falls, GI problems, nutritional deficiencies, delirium in hospital. Head, neck, and esophagus cancers are associated with chronic alcohol abuse. Liver cancer with cirrhosis is side effect of chronic alcohol abuse. Treatment consists of benzodiazepines, as well as thiamine and other vitamin supplements.

What are the lab values that could show malnutrition in the older adult?

• Serum albumin: Less than 3.5 g/dl is associated with malnutrition and increased morbidity and mortality Serum prealbumin <15 mg/dl (best marker) Serum transferrin <200 mg/dl Total lymphocyte count <1500/mm3 Total cholesterol >160 mg/dl

Hispanic Americans - top 5 health disparities

congenital syphilis, new case of TB, new cases of AIDS, exposure to particulate matter, and cirrhosis deaths

List and describe the care options for the older adult?

• • Independent living with help: Cooks, companions, homemaker/cleaning service—formal or informal. • • Family: Usually informal; may live in patient's or family member's home. • • Adult daycare at a facility: Part-time temporary assistance, frequently for respite or while a family caregiver works; often used for persons with dementia or for the frail elderly needing assistance or at risk for social isolation. Usual discharge is to assisted living or death. • • Adult daycare at home: Part-time respite, as above. • • Senior living complexes/continuing care/supported care retirement communities: Full range or limited services, depending on the community and level of assistance needed; can be progressive as needs increase. • • Assisted living: Homelike setting with more physical and medical care available than in senior complexes. • • Paid caregiver homes (licensed or unlicensed): Caregivers accept one or several nonrelatives into their home to receive 24-hour assistance, especially with BADLs, usually on a private-pay basis. In some states, public subsidies may cover adult group/foster home care. • • Extended care facilities: Skilled or intermediate care nursing home facilities for rehabilitation or ongoing care; can be paid by Medicare, Medicaid, or private pay, depending on financial resources. Preadmission screening is usually required by the state regulatory agency.

Explain the general guidelines to dietary counseling.

• • Limit alcohol to one drink a day for women, two daily for men. • • Limit fat and cholesterol. • • Maintain a balanced caloric intake. • • Ensure adequate daily calcium, especially for women. • • Older adults should consume vitamin B12 in crystalline form, which can be derived from fortified cereals and supplements. • • Older adults who have minimal exposure to sunlight or who have dark skin need supplemental vitamin D. Daily vitamin D intake should be 400-600 IU and can be derived from fortified foods or supplements. • • Include adequate whole grains, fruits, and vegetables. • • Drink adequate water.

Describe the pain assessment tools, and explain how unrelieved pain can lead to prolonged hospitalization.

A pain assessment, such as a 0-10 scale or a faces pain rating scale, should be used to determine pain intensity. For more impaired clients, the nurse should assess for crying, moaning, groaning, and other verbalizations that may be indicative of pain, along with possible nonverbal expressions of pain Possible Nonverbal Expressions of Pain Agitation, Increased confusion, Decreased mobility, Combativeness, Resistance to care, Guarding, Grimacing, Restlessness, Changes in eating and sleeping habits, Withdrawal, Aggression, Rubbing/holding a particular area of the body, Rapid breathing Unrelieved pain in the elderly can result in decreased cough, decreased gastrointestinal motility, an increase in negative feelings, a preoccupation with the pain, and a longer hospital stay. Pain in the elderly is particularly problematic. "Unrelieved pain can contribute to unnecessary suffering, as evidenced by sleep disturbance, hopelessness, loss of control and impaired social interactions. Pain may actually hasten death by increasing physiological stress, decreasing mobility, contributing to pneumonia and thromboemboli".

Make sure you understand what advance directives and living wills are as well as DNR and AND request. What is the nurse's role in this? What are the steps to initiating and caring out the patients request especially when family disagrees

Advance directive: Legal document that records decisions regarding life-saving or life-sustaining care and actions to be taken in a situation where the patient is no longer able to provide informed consent. Living wills are alternative documents that direct preferences for end-of-life care issues, providing an "if...then..." plan. They often include what type of care to provide and whether resuscitation measures should be taken. The "if" condition (e.g., If I am terminally ill and not expected to recover) must be confirmed by a physician. Do not resuscitate (DNR): A physician's written order instructing health care providers not to attempt cardiopulmonary resuscitation (CPR) in case of cardiac or respiratory arrest Allow Natural Death (AND) -Used as an advance directive in some locations instead of a DNR (do not resuscitate) order; promotes a more positive approach to consideration of a person's wishes at end of life

Recognize aspects of care, including pain and symptom management as priorities that contribute to a dignified end-of-life experience.

Among the nurse's primary responsibilities as a member of any interdisciplinary team is to coordinate the patient's care and to assist with symptom management. The remainder of this chapter will provide practical assistance with managing the variety of symptoms frequently encountered at end of life. Dyspnea means a distressing difficulty in breathing. It is a symptom, not a sign. A patient may have difficulty breathing and have no abnormal physical signs. Dyspnea, like pain, is whatever the patient perceives it to be. Episodic shortness of breath is sometimes due to hyperventilation. Any patient with dyspnea is prone to episodes of anxiety or panic. The goal of treatment for terminal dyspnea is to relieve the perception of breathlessness. Opioid therapy is used to treat shortness of breath. Morphine reduces the inappropriate and excessive respiratory drive. A low dose is usually very effective—liquid morphine 2.5-5 mg PO every 4 hours is a good starting dose. It may also be given subcutaneously at one-third the oral dose if the patient is unable to swallow. It reduces inappropriate tachypnea (rapid breathing) and overventilation of the large airways (dead space). It does not cause CO2 retention and can reduce cyanosis by slowing ventilation and making breathing more efficient. Morphine does not depress respirations when used judiciously and titrated appropriately. For patients who do not tolerate morphine, other opioids such as oxycodone and hydromorphone can be used. Anxiety can be precipitated by the fear of suffocation, which worsens the perception of dyspnea, creating a vicious cycle. Anti-anxiety agents, such as lorazepam 0.5-2.0 mg every 4-6 hours PRN, will help with restlessness and thus often decrease respiratory effort. It can be given PO, SL, bucally, or rectally. Oxygen may not be effective if hypoxemia is not the cause of dyspnea, but may have a placebo effect and decrease the individual's anxiety. O2 should be started at 2 lpm/nc; increase to 4 lpm/nc if needed. Other helpful and practical techniques might include: • • Head of the bed elevated 30-45 degrees • • Cool, humidified air • • Relaxation techniques • • Fan at bedside or ceiling fan Excess secretions, resulting from fluid overload from artificial hydration or from increasing inability to swallow secretions, allow a buildup in large airways and cause a rattling sound. This rattle may be more distressing to the family at bedside than uncomfortable for the patient. Scopolamine TD or SQ or hyoscyamine SL may be helpful in treating this condition. Rather than withholding opioids, the constipating side effects of the medications must be treated. A combination softener/stimulant should be used, because use of a softener alone could lead to a soft impaction. Nausea/vomiting, while common at end of life, may have multiple causes. Treatment of choice depends upon which of four areas of the brain are stimulated. One or more of these areas sends a message to the vomiting center located in the mid-brain, causing emesis. For this reason, a combination of medications may be required to control nausea and vomiting. Storey (1986) lists the following four areas: • 1. Cerebral cortex o • Stimulated by overwhelming visual, sensory, or cognitive input o • Anxiety—may control with lorazepam o • Brain metastases (due to intracranial pressure) o • May respond to dexamethasone • 2. Vestibular apparatus o • Inner ear responsible for motion sickness (e.g., infection or Meniere's disease) o • May respond to cyclizine, meclizine, or hyoscine • 3. Chemoreceptor trigger zone (CTZ) (most common causes of nausea are mediated by this route) o • Triggered by uremia, hypercalcemia, chemotherapy, and certain drugs o • Mild—may respond to hyoscine patch or promethazine o • More severe—may respond to prochlorperazine suppository or a more potent CTZ antiemetic like haloperidol • 4. Gastrointestinal tract o • Caused by noxious material in stomach, peptic ulcers, severe constipation, or bowel obstruction o • "Squashed stomach syndrome" or bowel obstruction—may respond to halperidol o • Delayed gastric emptying—use metoclopramide Anxiety at end of life can be caused by a variety of factors. Loss of control, loss of self-esteem, and loss of independence can be very distressing to a person who has previously been autonomous. A change in environment for the dying person may add to the anxiety. These changes may be large—as in a family caregiver, a place of care, or meeting new professional staff—or small, such as a change of bed or medication. Treatment for anxiety includes relieving physical symptoms that may be present, such as pain or shortness of breath. The simple presence of someone the dying person trusts can be very reassuring. Anti-anxiety medications may also be used in conjunction with these interventions. Delirium is a fluctuating cognitive disturbance, characterized by changes in mental status over a short period of time. It occurs in the last hours to days of life in a large percentage of dying patients. Delirium is especially devastating to family and friends because it can stand in the way of meaningful conversations and good-byes. The most common physical causes may include dyspnea, pain, constipation, or urinary retention, all of which can be treated. Environmental comfort can be provided by reducing stimuli, reorientation if possible, familiar persons at bedside, and interdisciplinary team members providing emotional, social, and spiritual support. Music therapy, therapeutic/healing touch, and nonmedical nursing interventions should be considered. Anti-anxiety medications, used cautiously, may also be helpful.

Explain CDT (Clock Drawing Test)--commonly done with the Mini-Cog evaluation.

The clock-drawing test, in which the client is asked to draw a clock face and indicate a particular time, is a sensitive but nonspecific screening test.

Define autonomy and self-determination.

Autonomy: Referring to self-governance or self-directing freedom; being in charge of one's own being; having moral independence. the concept that each person has a right to make independent choices and decisions. Self-determination - the process by which a person controls their own life. Patient has right to decide.

BEER's List of Inappropriate drugs to use in older adults

Benzodiazepines are mentioned quite a bit. Medications to Avoid in the Elderly Medication Effect Propoxyphene (Darvon) and combination products (Darvon with ASA, Darvon-N, and Darvocet-N) Offers few advantages over acetaminophen, yet has the same adverse effects as other narcotic medications Amitriptyline (Elavil), chlordiazepoxide-amitriptyline (Limbitrol), and perphenazine-amytriptyline (Triavil) Strong anticholinergic and sedation effects Diphenhydramine (Benadryl) May cause confusion and sedation; use in smallest possible dose for emergency allergic reactions All barbiturates, except when used to control seizures Highly addictive, more adverse effects in the older adult Meperidine (Demerol) May cause confusion Short-acting nifedipine (Procardia and Adalat) Potential hypotension and constipation Clonidine (Catapres) Potential for orthostatic hypotension and CNS adverse effects Mineral oil Potential for aspiration and adverse effects; other options readily available Estrogens only Lack of cardioprotective effect in older women; evidence of carcinogenic potential Nitrofurantoin (Macrodantin) Potential for renal impairment; other alternatives available Cimetadine (Tagamet) CNS effects including confusion Indomethacin (Indocin and Indocin SR) CNS adverse effects; other NSAIDs available with fewer adverse effects Methocarbamol (Robaxin), carisoprodol (Soma), chlorzoxaxone (Paraflex), cyclobenzaprine (Flexeril), oxybutynin (Ditropan) Anticholinergic effects, sedation, weakness Short-acting dipyridamole (Persantine) Orthostatic hypotension Methyldopa (Aldomet) and methyldopa-hydrochlorothiazide (Aldoril) May cause bradycardia and exacerbate depression in older adults

Some patients have several deficits that affect communication abilities. Consider patients who are post CVA, TBI, or paralysis and what technology could be utilized to assist them with effective communication

Broca's aphasia is a nonfluent, agrammatic expressive aphasia. They have good auditory comprehension and are able to understand but have difficulty producing intelligible speech. Communication - patience!!! Wernicke's aphasia is a fluent aphasia. They are able to speak, although the speech may contain odd words/sounds. They have impaired auditory comprehension and has great difficulty understanding what is said. Rely on nonverbal gestures. NEED SPEECH THERAPY Dysarthria - may be difficult to understand when they are speaking. Patience !!! May use assistive technology to augment or replace vocal communication. Encourage to speak slowly and use simple sentences or single words. Allow time for patient to respond. If there is no speech - assess the patient's yes/no reliability; use a picture board or eye blink. May use writing, typing or communication board. Deaf - use qualified sign language interpreters Paralysis - depending on the type, but communication is difficult. ALS(as it progresses) or a pontine stroke - they can not produce speech or use their hands to express. They are aware of the environment but with no motor function below the level of the eyes, it is difficult to effectively communicate to others. Use of electronic form of communication, either by blink of eye or use of reflector dot (worn on forehead) and they can move the mouse around to type words.

Describe effects of grief and mourning on older adults and their families

The elderly are confronted with a variety of losses in many aspects of their lives, not just with the death of a spouse, family members, or long-time friends. Loss of bodily function occurs as illness becomes more prevalent. Loss of support systems and family and friends occurs as companions die. Loss of independence is a factor as one's physical abilities wane, including loss of mobility, decision making, and access to various other support systems. Not only are the bodily functions lost, but the realization of never regaining these functions is particularly difficult. Primary losses are the loss of people close to them—spouses, children, parents, or siblings. Secondary losses are those resulting from the primary loss—companionship, roles the deceased assumed in the relationship (e.g., bill payer, cook), and independence. Although the terms grief and mourning are frequently used interchangeably, each does have a specific meaning. Grief is the natural and normal response to loss of any kind and is experienced psychologically, behaviorally, socially, and physically. It involves many changes over time . Mourning is the cultural and/or public display of grief through one's behaviors. These include accepting the reality of the loss, reacting to the separation and finding ways to channel the reactions, handling the unfinished business, and transferring the attachment to the deceased from physical presence to symbolic interaction. It seeks to accommodate the loss by integrating its realities into ongoing life distinguishes mourning as the shared social response to grief—grief gone public. Mourners must be given the opportunity to process the aspects of their grief, but in a context that is helpful to them. Nurses, who are likely to frequently encounter grieving patients, can facilitate the mourning process by being aware of the aspects of grief and mourning, and by advocacy with the people who surround the mourner. Mourner's Bill of Rights to help mourners sift out the unacceptable advice they are often given. This includes the right to: • • Experience unique grief, without the pressure of "shoulds/shouldn'ts" • • Talk about grief, or be silent as needed • • Feel a multitude of emotions, without feeling judgment • • Tolerate physical and emotional limits, and fatigue • • Experience sudden surges of grief • • Use rituals • • Embrace spirituality, or not • • Search for meaning, recognizing some questions may not have answers • • Treasure memories; share them • • Move toward grief and heal; avoid people who are intolerant of your grief • • Recognize that "grief is a process, not an event" Other ways nurses can help include active listening without judging the mourner; having compassion and allowing the expression of feelings without criticizing; allowing the mourner to identify his or her own feelings without saying, "I know how you feel"; and offering presence over time.

Describe the use and purpose of the various special tools that have been proven to produce accurate results for assessment of the older adult.

Confusion Assessment Method (CAM), to assist nurses and others to identify delirium quickly and accurately using the four basic features of delirium: 1) acute onset or fluctuating course, 2) inattention, 3) disorganized thinking, and 4) altered level of consciousness. A diagnosis of delirium is made if both features 1 and 2 are present along with either of features 3 or 4. Mini Mental State Examination (MMSE): A brief series of questions to help determine the presence of cognitive impairment. Test the elder's orientation, registration, attention and calculation, recall and visouspatial skills. If the score is <20, it indicates cognitive impairment. The Clock Drawing Test (CDT) component of the Mini-Cog TM allows clinicians to quickly assess numerous cognitive domains including cognitive function, memory, language comprehension, visual-motor skills, and executive function and provides a visible record of both normal and impaired performance that can be tracked over time. SPICES is an acronym for the common syndromes of the elderly requiring nursing intervention: S is for Sleep Disorders P is for Problems with Eating or Feeding I is for Incontinence C is for Confusion E is for Evidence of Falls S is for Skin Breakdown

Explain the differences between curative, palliative, and end of life or hospice care.

Curative -Medical care focused on healing/ cure of disease Palliative - Concept of care designed to promote comfort and holistic management of symptoms at any stage of illness or disease. Palliative care refers to the comprehensive management of the physical, psychological, social, spiritual, and existential needs of patients. It is especially suited to the care of people with incurable, progressive illnesses. The goal of palliative care is to achieve the best possible quality of life for patients and their families. Control of pain, of other symptoms, and of psychological, social, and spiritual problems is paramount End of Life -Last stages of living; in this context usually caused by a terminal illness Hospice Care -A program to deliver palliative care to individuals in the final stages of a terminal illness; additionally provides personal support and care to the patient, and supports to the patient's family/caregivers while the patient is dying; provides bereavement support after the patient's death. Hospice care originated in order to provide comfort and dignity at end of life. Eligibility for hospice services is based on a life expectancy of 6 months or less, if an illness runs its normal course. Services are available as long as a patient is considered to be terminally ill, even though it may be longer than 6 months. Hospice utilizes a team approach to address the physical, emotional, social, and spiritual needs of the patient and family.

Explain the Triple Aim of healthcare reform

Developed by the Institute of Healthcare Improvement that describes an approach to optimize health system performance. Triple Aim is : Improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

What is frailty? What are the characteristics?

General decline in the physical function of older adults. Defining characteristics include unintentional weight loss of more than 10% in the prior year, feelings of exhaustion, grip strength in the weakest 20% for age, walking speed in the lowest 20% for age, and low caloric expenditure (<270 kcal) per week on physical activity. Neither age nor disability alone makes a person frail, but changes that often occur with age may contribute significantly to its presence. At nearly every age past 65, women commonly experience frailty at a greater percentage than men. Sarcopenia (loss of muscle mass), Osteoporosis; muscle weakness. To prevent frailty, older adult needs to maintain healthy diet and weight, stay active, practice fall prevention, make connections, maintain relationships, and see doctor regularly

Discuss Healthy People 2010 and 2000.

Healthy People 2010 is an initiative of the U.S. Department of Health and Human Services that utilized the skills and knowledge of an alliance of more than 350 national organizations and 250 state public health, mental health, substance abuse, and environmental agencies to develop a set of health care objectives designed to increase the quality and quantity of years of healthy life of Americans and to eliminate health disparities. Healthy People 2000, was initiated by the U.S. Public Health Service in another effort to reduce preventable death and disability for Americans.

Compare Healthy people initiative 2000 and 2010

Healthy People Initiative 2000 - initiated by the U.S. Public Health Service to reduce preventable death and disability for Americans. Older Americans did not reach the target goals in areas of physical activity, being overweight, and eating fruits and vegetables. Failing grades also in reducing hip fractures in >65 years and fall related deaths in >85. Financial assistance was provided through Medicare for mammogram coverage, pneumococcal vaccination, and influenza vaccination. Healthy People Initiative 2010 - initiated of the U.S. Department of Health and Human Services that utilized the skills and knowledge of an alliance - to develop a set of health care objectives designed to increase the quality and quantity of years of healthy life of Americans and to eliminate health disparities.

Describe the environmental risk factors that can be dangerous for an older adult. Explain ways to modify the environment to address these safety issues.

In the inpatient setting, orientation to the environment with an emphasis on safety devices is the first step in preventing falls. Other strategies include nonskid slippers or shoes, hip protectors, removal of obstacles and clutter, having the commode close to the bed, having the call light within easy access, and encouraging use of glasses and hearing aids. The avoidance of physical restraints, such as raised side rails, and maintaining the bed in the lowest position are essential in reducing the severity of falls. Side rails are a common physical restraint that are used to prevent falls but often result in more serious injury because patients attempt to climb over them and may fall from a greater height. Similar interventions applicable to the community setting include removing clutter, throw rugs, and cords and wires; installing handrails on stairs, bathtubs, and showers; using rubber bath mats in the shower and tub; installing a raised toilet; marking stairs and thresholds with fluorescent tape; encouraging the use of eyeglasses and hearing aids; and maintaining adequate lighting throughout the house. Adequate lighting includes installing night-lights throughout the house, using 100-watt nonglare lightbulbs (ceiling lights are best), placing a light switch at the entrance to prevent the elder from entering a dark house or rooms, and ensuring that all stairwells and hallways are well lit to avoid shadows. Patients on four or more medications are at a higher risk for falls. Special attention should be given to drugs that affect mobility such as sedatives, hypnotics, psychotropics, and antihypertensives. Patients should be taught about interventions to prevent postural hypotension such as changing positions slowly to prevent syncope. When beginning a new medication, elders should be monitored closely, especially if the medication has the potential to affect mobility, balance, and/or cognition

Native Americans

Insulated from the rest of the country, either literally (by way of land reservation) or in other ways such as linguistically. Follow naturalistic approach, believing that health is a balance of the mind, body, and spirit, and illness occurs when there is an imbalance or disharmony with nature. Health beliefs are blended with religion, carrying a magic facet as well as holistic and naturalistic approaches

Describe the interdisciplinary team, including; Who is usually on the team, Who is most likely not going to be at a meeting, and What the team's purpose is, and the role of the nurse.

Interdisciplinary team: A team in which members of various disciplines interact, collaborate, and work together for common goals. Interconnected group of professionals who have common and collective goals. THE GERIATRIC TEAM CAN IDENTIFY NEEDS BASED ON A WIDE ARRAGE OF ASSESSMENT PARAMETERS. WORKING TOGETHER ALLOWS THE PATIENT TO BE SEEN AS A WHOLE AND TREATMENT TO BE MORE EFFECTIVE. Beyond the client, teams may include any combination of geriatricians, RN's, NP's, Clinical Nurse Specialist, physicians, PA's, social workers, psychologist, psychiatrists, pharmacists, OT's, PT's, speech pathologist, dieticians, discharge planners, and chaplains. Audiologist - hearing assessment including audiometric studies, evoked potentials, and other diagnostic procedures, and treatment of hearing loss. Caregiver- varying degrees of expertise. Chaplain, Priest, Rabbi, Minister - provide support to client/patient, family, and others as it relates to spiritual needs. May assist in identifying resources from within congregation for support, visitation, or respite. Client/patient - life experience, expert in their experience. Dietician - assess nutritional status and implementation of a nutritional plan Geriatrician - Licensed medical physician with fellowship in gerontology post medical internship and residency. Use knowledge of normal aging as part of assessment. Advance practice Gerontological nurse practitioner (GNP) - May also be prepared at the Doctor of Nursing Practice level with same certification and licensure. Provide advanced care for older adults, their families, and significant others in a variety of setting. Occupational therapist - may also be prepared as a Doctor of OT. Assess and treat functional, sensory, and perceptual deficits that impart on ADL's, assess need for assistive devises, assess and treat cognitive deficits, rehabilitative series in geropsychiatrics. Physical therapist - assess mobility and functional capacity of the elderly, treatment includes rehabilitation, strengthening, mobility, and use of assistive devices Pharmacist - Certification available as geriatric pharmacist, prepare and dispense medication, clinical consultation and education for patient and geriatric team. Physician/PA Psychiatrist - Geropsychiatry evaluation, treatment, and management of mental health issues faced by the elderly, includes pharmacotherapy, evaluation of cognition, and psychotherapy. Psychologist - Gerpsychology assessment, consultation, intervention, and management of conditions related to adaptation, bereavement, counseling and treatment for clinical cognitive and behavioral needs. RN - assessment, planning, providing, coordinating, and evaluating care, which focuses on health, optimal wellness, disease prevention, and advocacy. Social worker - assist with coping and problem solving as individuals and families adjust and face changes with aging and chronic illness Speech language pathologist - assess and treat communication disorders, which include speech, language, hearing, swallowing, and cognitive deficits.

What are intrinsic risk factors? What are extrinsic risk factors?

Intrinsic risk factors relate to the changes associated with aging and with disorders of physical functions needed to maintain balance. These functions include vestibular, proprioceptive, and visual function, as well as cognition and musculoskeletal function. Elderly persons who fall in institutions are usually more physically and/or cognitively impaired, and therefore intrinsic factors contribute most to falls and fall-related injuries. Extrinsic risk factors are related to environmental hazards and challenges such as poor lighting, stairs, clutter, and throw rugs. Extrinsic factors are implicated in up to 50% of all falls in the elderly in community settings. In institutionalized patients, the use of restraints and bed rails may increase the risk of falls because patients attempt to free themselves from these constraints.

What is the Kohlman Evaluation of Living Skills (KELS)?

It assesses 17 daily living skills under five categories—self-care, safety and health, money management, transportation and telephone use, and work and leisure

Identify tool that can enhance the function of some physical or mental ability that is impaired (i.e., cane, walker, glassed, hearing aids, wheelchair, bath bench, elevated toilet seat).

It is anything that can enhance the function of some physical or mental ability that is impaired

Explain whether or not older adults at risk for alcohol abuse. If yes, explain what can be done to re-educate them and prevent harm.

It is very difficult to diagnose alcohol problems in the elderly for several reasons. Retired people do not have the lifestyle disruptions caused by heavy alcohol use that are commonly encountered in younger adults. They are less likely to be arrested due to disorderly conduct or aggression related to their drinking. Alcoholics over the age of 65 are more likely to be living alone and drinking alone, than younger adults. On the other hand, the older drinker is more likely to honestly report his or her drinking to the health care provider and is more likely to comply with treatment strategies SEE #20

Determine the needs and wishes of patients nearing the end of life

It may be possible to plan for a peaceful death, given the knowledge of having a terminal illness. "The key to peaceful dying is achieving the components of peaceful living during the time you have left" (Preston, 2000, p. 161). Some components are accomplished only by the individual, whereas others may require the assistance of family and medical providers, such as the following (Preston, 2000): • • Instilling good memories • • Uniting with family and medical staff • • Avoiding suffering, with relief of pain and other symptoms • • Maintaining alertness, control, privacy, dignity, and support • • Becoming spiritually ready • • Saying good-bye • • Dying quietly A good death is possible and can be facilitated by the nurse who advocates for and works to ensure that the patients, families, and caregivers are free from avoidable distress and suffering, that the process is in accord with the wishes of the patient and family, and that it is consistent with clinical, cultural, and ethical standards

Communication with a delirious elder

Keep discussions simple and questions concise. Use large print calendars and clocks to assist with orientation. Pictures of family may assist in reorienting. Well lit room. Offer frequent reassurance. Avoid physical restraints Use distraction and soothing conversation.

Communication with dementia

Make sure the person is attending to you prior to beginning the conversation. Face the person Speak slowly and clearly. Eye level Reduce or limit background noise. Break tasks into small manageable steps and provide simple and clear directions ( one step at a time may be needed ) Praise efforts. Use concrete terms and familiar words. Offer simple choices. Allow adequate time to respond. Do not argue or attempt to reason with someone regarding delusions or hallucinations. Encourage discussion of life events, traditions, memories. Use large print calendards Label items Establish a familiar environment

Polypharmacy- why is the older adult more apt to polypharmacy?

Many older patients are prescribed multiple drugs, take over-the-counter medications, and are often prescribed additional drugs to treat the side effects of the medications that they are already taking. They may see several different health providers

Elder abuse is often referred to as a silent crime with many case going unreported. Because of this the student should be aware of the classic cues that abuse may have taken place with the elderly. There are many factors that place an older adult at risk for abuse or neglect. Students should be aware of their local protocols when abuse or neglect is suspected.

May include physical, sexual, psychological, and financial exploitation, neglect, and violation of rights. Physical abuse - shaking, restraining, hitting, or threatening with objects. Psychological -threats, insults, or harassment, harsh commands. Financial - form of scams, family misuse of money or possessions. Neglect - intentional or unintentional of required food, medication, or personal care is not provided. Abandonment is a form of neglect. Reporting to adult protective services agency is MANDATORY .

Describe Part A and Part B of Medicare.

Medicare A - hospital, includes inpatient care at hospital, SNF, and hospice. Covers services like lab tests, surgery, doctor visits, and home health care Medicare B - (medical insurance) covers doctor and other health care provider services, outpatient care, DME, home health care and some preventive services.

Define health promotion vs. health screening.

Model health promotion programs: Programs that have received federal funding and foundation support to evaluate their effectiveness, and to encourage their replication. Health screening are tests that look for diseased before you have symptoms. Screening can find diseases early.

There are three types of assessments: Physical , Cognitive and Functional

Physical - assess physical health. It includes VS, assess for pain, BP problems, irregular heartbeat, abnormal breath sounds, etc. Functional - assessing what the older adult can still do for him or herself. Bathing, eating, dressing, etc. Dr. Katz and Dr. Barthel developed ADL/IADL indexes to measure the functional abilities. Cognitive - addresses thought processing, thinking and reasoning skills. Normal cognitive changes - Decline in information processing speed, divided attention, sustained attention, ability to perform visuospatial tasks, and short-term memory.

Preventive measures such as flu and pneumococcal vaccines

Pneumococcal - >65.one dose if not previously received, followed with dose at least one year after the most recent dose. Influenza -yearly by October Zostavax >60 Tetanus -every 10 years

What are the signs of impending death?

Recognizing that although each person approaches death in his or her own way, there are some identified patterns that assist in the recognition of end-stage status, noted in common language for ease of comprehension by patients and families. One to three months: • • Withdrawal from the world and people • • Decreased food intake • • Increase in sleep • • Going inside of self • • Less communication One to two weeks: Mental changes: • • Disorientation • • Agitation • • Talking with the unseen • • Confusion • • Picking at clothes Physical changes: • • Decreased blood pressure • • Pulse increase or decrease • • Color change (pale, bluish) • • Increased perspiration • • Respiration irregularities • • Congestion • • Sleeping but responding • • Complaints of body being tired and heavy • • Not eating, taking little fluid • • Body temperature hot/cold Days or hours: • • Intensification of 1- to 2-week signs • • Surge of energy • • Decrease in blood pressure • • Eyes glassy/tearing/half open • • Irregular breathing • • Restlessness or no activity • • Purplish/blotchy knees, feet, hands • • Pulse weak and hard to find • • Decreased urine output • • May wet or stool the bed Minutes: • • "Fish out of water" breathing • • Cannot be awakened

Explain Bailey's Bull's eyes.

The goal of the bull's-eye is for people to consume the nutritious foods that are listed in the center of it. These foods are low in saturated fat, sugar, and sodium, and high in fiber. They include skim milk, nonfat yogurt, most fruits and vegetables, whole grains, beans and legumes, and water-packed tuna. As you move to the foods listed in the rings farther away from the bull's-eye, you eat more saturated fat, sugar, sodium, and low-fiber foods. In the outer ring of the bull's-eye, therefore, are most cheeses, ice cream, butter, whole milk, beef, cake, cookies, potato chips, and mayonnaise.

Describe the 2 main categories of pain-- Nociceptive pain and Neuropathic pain. Identify the types of Somatic nociceptive pain typically involves the following symptoms and treatments:

Somatic nociceptive pain typically involves the following symptoms and treatments • • Tissue injury resulting in stimulation of afferent nerve endings. • • The skeletal system, soft tissue, joints, skin, or connective tissue. • • The patient typically can localize the pain, may be able to point with finger to area; may describe as dull, aching, throbbing, or gnawing in nature. • • Best treated with NSAIDs or steroids, and partially responsive to opioid therapy; may require a combination. • • Examples: bone fracture, bone metastases, muscle strain. Visceral nociceptive pain typically involves the following: • • Activation of nociceptors • • Internal organs • • Patient often unable to localize; may use an open hand to show area affected, because pain may be diffuse • • May describe as deep, aching, cramping, or sensation of pressure • • Very responsive to opioid therapy • • Examples: shoulder pain, secondary to lung or liver metastases Neuropathic pain typically involves the following: • Injury to peripheral nerves or central nervous system • • May be described as shooting, stabbing, burning, or shock-like • • May be constant or intermittent • • Less responsive to opioids; responds best to anticonvulsants or tricyclic antidepressants • • Examples: herpes zoster or diabetic neuropathy medications that work the best with these types of pain.

Explain what you can do to prevent falls.

Suggestions of possible changes to the environment, facilitation of modifications, and training in the use of adaptive equipment were helpful in reducing the number of falls in a group of frail elderly with a history of falls. However, modifications to the environment alone were not sufficient to make the difference. Compliance with the physical changes as well as with the suggested behavioral changes was also important.

Explain the intention of The Patient Protection and Affordable Care Act and identify the provisions that have already taken effect.

The Affordable Care Act intentions reform healthcare system by providing more Americans with affordable health insurance, implements measures that will lower heath care costs and improve system efficiency , and eliminate the denial of coverage due to pre existing conditions

What is a healthy weight or BMI and when should we be concerned?

The BMI is a number usually between 16 and 40. A BMI between 25 and 29 is considered "overweight" and more than 30 is considered "obese."

Explain the chronic disease self-management program (CDSMP).

The Chronic Disease Self-Management Program (CDSMP) is a 17-hour course for patients with chronic diseases that is taught by trained laypeople. The course goal is to teach patients to improve symptom management, maintain functional ability, and adhere to their medication regimens.

Review each of the transitions models provided in the COS and what they attempt to accomplish

The Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults identifies 10 screening criteria developed and modified based on the results of completed randomized clinical trials of older adults with common medical and surgical DRGs (e.g., heart failure, angina, cardiac surgery, etc) and found to correlate to higher risk on transition from hospital to home. A major strength of the Transitional Care Model (TCM) Hospital Discharge Screening Criteria for High Risk Older Adults is its ability to identify patients at high risk for poor outcomes after hospitalization for an acute or exacerbated chronic illness. This screening is easy and quick to administer and does not require advanced training to complete. All of the instruments used in the screening can be found as part of the Try This series. There are no limitations to completing the screening as outlined, only the ability to refer and availability of transitional care services in many settings. Any suspected or diagnosed cognitive impairment with or without the screening criteria would independently trigger postdischarge intervention to assure appropriate information transfer and follow-up after discharge to home or other care setting. Health Care Leader Action Guide to Reduce Avoidable Readmissions - four steps are: Examine your hospital's current rate of readmissions. Assess and prioritize your improvement opportunities. Develop an action plan of strategies to implement. Monitor your hospital's progress.

Compare the benefits and limitations of the major forms of reimbursement on the delivery of healthcare services to older adults, differentiating the roles of Medicare and Medicaid

The are government sponsored healthcare programs. Medicare is primarily for seniors 65 and older and disabled individuals who qualify for social security. Severe disabilities and ESRD are also eligible. Medicaid is assistance program that covers low to no income families/individuals. Some may be eligible for both.

Describe a health contract

The health contract/calendar relies on the self-management capability of a client, after initial assistance is provided by a clinician or health educator. The client is helped to choose an appropriate behavior change goal and to create and implement a plan to accomplish that goal. The statement of the goal and the plan of action are then written into a contract format. A health contract is alleged to have several advantages over verbal communication alone, especially when the communication tends to be limited in direction (i.e., mostly from health professional to client). The alleged advantages of a contract, which still need additional empirical testing, are that it is a formal commitment that not only enhances the therapeutic relationship between provider and client, but also requires the active participation of the client. The contract also: • • Identifies and enhances motivation • • Clarifies measurable and modest goals • • Suggests tips to remember new behaviors • • Provides a planned way to involve support persons such as family and friends

Identify legal and ethical standards related to end-of-life care.

The most fundamental patient right is the right to decide. The Patient Self-Determination Act of 1990 was enacted to reduce the risk that life would be shortened or prolonged against the wishes of the individual. Following the belief that each person has a fundamental right to decide (autonomy), this law requires that patients are provided the opportunity to express their preferences regarding lifesaving or life-sustaining care on entering any health care service, including hospitals, long-term care centers, and home care agencies. The law also requires that adequate information be supplied to the patient so that he or she can make informed decisions regarding self-determination. Decisions regarding life-saving or life-sustaining care are recorded in legal documents known as advance directives. Advance directives describe actions to be taken in a situation where the patient is no longer able to provide informed consent. A living will may include a durable power of attorney, a legal document designating an alternative decision maker in the event the person is incapacitated. This document supersedes all other general legal designations for decision makers. In other words, a patient may designate a close friend with durable power of attorney, superseding the designation of immediate family members in decision making in a situation where the patient is incapacitated. The living will in this situation provides direction to the decision maker. The use of a durable power of attorney can decrease conflicts between family members and allows the designated decision maker to perform in roles negotiated in advance with the patient. The absence of a living will or "do not resuscitate" order requires that all possible efforts at resuscitation should be initiated. Care of the incapacitated person is greatly simplified by an advance directive or living will. However, the issues of paternalism and boundary violations can cause ethical conflicts in the pursuit of such directives if not handled empathetically. It is imperative that information be supplied in an ethically appropriate manner for each patient because the manner in which alternatives are discussed greatly influences choices made. If a physician determines a person is no longer competent for such decision making, it should be noted in writing with an explanation of the probable cause and its likely duration. This allows the nurse to follow legal and institutional guidelines for using an advance directive or alternative decision maker

Explain the effects of restraint use on the elderly

The use of physical restraints increases the risk for falls, confusion, death by strangulation, and complications of immobility (e.g., contractures, pressure ulcers, pneumonia, UI, and learned helplessness). Physical restraints are not recommended, because they may increase fear and agitation. Distraction and soothing conversation should be tried instead.

Baby Boomers unique characteristics that make them a challenge for healthcare professionals

They expect and demand excellence in geriatric care. Health disparities exist among minority elder group. Other vulnerable older adults are veterans, those with disabilities, and prisoners.

What are other disease processes the older adult is at risk for? Explain the prevalence and how to prevent or control the illness

Thyroid dysfunction -Older adults are far more susceptible to thyroid dysfunction than younger adults. Overt disease affects 5% of American adults, but the prevalence of subclinical hypothyroidism (elevated thyroid-stimulating hormone [TSH] with normal levels of thyroid hormone) is 17.4% among women older than age 75 and 6.2% among men over age 65. Untreated hyperthyroidism can lead to atrial fibrillation, congestive heart failure, osteoporosis, and neuropsychiatric disorders. Hypothyroidism can cause constipation and ileus, lipid abnormalities, weight gain, decreased cognition, depression, and negative changes in functional status. The goal of screening would be to decrease the negative effects of overt thyroid disease. Osteoporosis -The risk for the development of osteoporosis markedly increases with age, and osteoporosis is responsible for 70% of the fractures that occur in older adults. Women ages 65-69 have 6 times the risk of osteoporosis than younger postmenopausal women, and that rate increases to 14 times in women ages 75-79. Age, low body mass index (BMI), and failure to use estrogen replacement are the strongest risk factors for osteoporosis development. Other possible risks include white or Asian race, family history of compression or stress fracture, fall risk or history of fracture, low levels of weight-bearing exercise, smoking, excessive alcohol or caffeine use, and low intake of calcium or vitamin D. Certain medications, such as thyroid medication or prednisone, increase the chances of developing osteoporosis. The risk associated with age alone was high enough that the USPSTF recommends routine screening for all women over the age of 65. If risk factors, especially weight less than 70 kg (about 154 pounds) and no estrogen therapy, are present, the task force suggests screening women at age 60. Bone density testing at the femoral neck by dual energy x-ray bone densitometry is the gold standard screening tool, and the one most closely correlated with hip fracture risk, though heel measurements using ultrasonography are also predictive of short-term fracture risk. Hearing and visual impairment -The prevalence of hearing and visual impairment increases with age and has been correlated with social and emotional isolation, clinical depression, and functional impairment. An objective hearing loss can be identified in over one-third of persons age 65 years or older and in up to half of patients age 85 years or older. High-frequency loss is the most important contributor to this increase in hearing loss, though up to 30% of cases may be caused or compounded by cerumen impaction or otitis media, which are easily treated. About 4% of adults ages 65-74 and 16% of those 80-84 years of age have bilateral visual acuity worse than 20/40. Macular degeneration is the most common cause of visual loss in elderly whites, whereas African Americans are more likely to lose vision as a result of cataracts, glaucoma, and diabetes. Visual impairment has been correlated with falls and hip fractures in the elderly. The Snellen eye chart is a useful tool for vision screening. Ophthalmology referral may be useful for clients whose corrected vision is worse than 20/40, or who report visual problems that limit activities such as reading or driving. Many expert panels, including the American Academy of Ophthalmology, the American Optometric Association, and Prevent Blindness America, recommend regular ophthalmologic exams for adults over 65 years of age (40 years of age for African Americans) based on the fact that effective glaucoma screening should be performed by eye specialists with specialized equipment to evaluate the optic disc and measure visual fields. The optimal frequency for glaucoma screening has not yet been determined. Prostate cancer is both the second most common form of cancer among U.S. men and the second leading cause of cancer death in U.S. men. The risk of developing prostate cancer increases with age and is the second leading cause of death in American men. The disease is most prevalent in African Americans and least prevalent among Asian Americans. Two tests are commonly used in prostate cancer screening: the digital rectal exam (DRE) and the prostate-specific antigen (PSA) blood test. Breast cancer is the most common cancer among U.S. women, and the prevalence of the disease increases with age. According to the CDC (2008), 3-4% of women who are 60 years old today will get breast cancer by the age of 70. Other risk factors for the disease include family history of breast cancer, atypical hyperplasia in breast tissue, and birth of a first child when a woman is over 30 years of age. The USPSTF examined whether breast cancer screening, by mammography, was beneficial in older women. Colorectal cancer is both the third most common cancer in the United States and the third leading cause of cancer death in the United States. The prevalence of the disease increases with age, and over 90% of colorectal cancer is diagnosed in clients over the age of 50. There are several good screening methodologies to detect early colon cancer: fecal occult blood testing (FOBT), sigmoidoscopy, and colonoscopy. Choice of screening test is determined based on client risk factors and preference. Patients who have a history of adenomatous polyps or inflammatory bowel disease, or a family history of colorectal cancer or adenomatous polyps, should receive colonoscopy. Screening for these high-risk clients is begun before age 50. Commonly used screening strategies for clients of average risk include annual FOBT, sigmoidoscopy performed every 5 years, or a combination of FOBT performed annually with sigmoidoscopy every 5 years when FOBT testing is negative. If the results of this test are positive, clients are sent for colonoscopy or double contrast barium enema combined with sigmoidoscopy, in cases where colonoscopy is not available. The best methodology for FOBT is the three consecutive stool samples that are collected at home by the patient on an annual basis. These tests should be examined without rehydration due to the decreased specificity of the test that is associated with rehydration of the samples. A single guiaic test, performed in the office with DRE, is not recommended as an adequate screening test

Identify the types of restraints used

Types of Physical Restraints Wrist and leg restraints; Wheelchair safety bars; Vest restraints; Mitts; Chairs with lapboards; Beds with side rails; Bedsheets; Lap belts Chemical restraints - Medication

Assistive technology is designed to fill the patient's gap in functional ability. This goes back to the ADLs and IADLs. What can they do and what can they not do. Can we put something in place to help them?

any item, piece of equipment or product system, that is used to increase, maintain or improve functional capabilities of individuals with disabilities.

Difference between delirium and dementia

delirium as: • 1. Disturbance of consciousness with reduced ability to focus, sustain, or shift attention • 2. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementia • 3. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate over the course of the day • 4. There is evidence from the history, physical examination or laboratory findings that the disturbance is caused by several different possible events including general medical conditions (cancer, AIDS), metabolic disturbances (including electrolyte disturbances as occurs with dehydration, drug intoxication, drug withdrawal, drug side effects, and multiple etiologies). dementia as: • 1. Development of cognitive deficits: o • The person cannot recall new or previously learned information. o • Memory problems must be present. • 2. One or more of the following: o a. Apraxia: Impaired motor activities due to damage to motor cortex (e.g., the person cannot use a key) o b. Aphasia: Language disturbance (e.g., cannot find words or put sentences together) o c. Agnosia: Failure to recognize or identify objects (e.g., the person may see something but cannot label it or tell what it is used for) o d. Disturbed executive functioning: Planning, organizing, sequencing, and abstracting problems due to frontal lobe damage

What is role reversal for the older adult?

elder moves from care provider to care recipient through the course of aging.

Native Americans - top 5 health disparities

fetal alcohol syndrome, smoking by pregnant women, alcohol related motor vehicle deaths, cirrhosis deaths, and new cases of gonorrhea

Identify the four leading causes of death in the US.

heart disease, stroke, cancer, and diabetes

Hispanic Americans

high values on family, religion, and community. Emphasize family interdependence over independence. They turn to family first before seeking outside health care. Seek the use of homeopathic remedies in conjunction with religious artifacts before engaging the health care professional. They disagree with is silence and noncompliance. May not seek health care because they feel that their illness/disease is a punishment of sins. Many do not seek health care because they do not have access to it (lack of insurance, communication difficulties, or fear of ramifications due to being in country illegally. Religion varies. Strive to achieve balance between "hot" or "cold" within the body. Illnesses are categorized as either hot or cold, and treated with reciprocal type of substance, found in either food or medicine. Diabetes and heart disease are two health problems that have increased within this cultural group

Describe what can be done to eliminate the problems of care transition.

improved communication, adequate patient education, family education, increase of access to community based transitional care services, improve transitions within acute hospital settings;

What are the risk factors for stroke? Describe the statistical data in regards to strokes and the older adult.

increased age, hypertension, smoking, diabetes, coronary artery disease, heavy alcohol use, cigarette smoking, sedentary lifestyle, and a high-fat diet, atrial fibrillation and asymptomatic carotid stenosis third leading cause of death in the United States, with more than two-thirds of stroke occurring in persons age 65 years or older. estimated that 36% of strokes suffered by clients 80-89 years of age are as a result of nonvalvular atrial fibrillation.

European Americans

individualistic, stoic (don't want to be a burden to others), elder Europeans lose their sense of self worth. Trust authority (will tend to follow health care advice)

What are the problems associated with patient transfers.

ineffective handoffs (transfer of information during the transition of care across the continuum. The handoff is largely dependent on the interpersonal communication skills of the caregiver as well as the knowledge and experience level of the caregiver.

What are the factors that influence the quality of life of an older adult?

influenced by health status, nutrition well being, spirituality, living arrangements, physical activity, social interactions, physical, mental, emotional function, disease management, independence. They are influenced by emotional, physical, economic, and social needs. Quality of life is enhanced by prevention and management of chronic disease through preventive care, support for healthy lifestyle choices, education, and home evaluations to reduce risk of injury. Maintaining maximum independence while maintaining maximum quality of life is a balance sought by the elderly, their caregivers, and society in general. Aspects of achieving this balance are often in conflict with each other and are certainly affected by the many factors involved in the aging process. Any evaluation of quality of life should include the perceptions of the person being evaluated. Even those with dementia are able to identify mood state, at times with more accuracy than their caregivers. Consideration of the whole person is important, and in so doing, the interdisciplinary team gains important information for developing evaluations, methods, and interventions.

Baby Boomers

large group of people born between 1946-1964. Considered more affluent, better educated and healthier. Baby boomers have entered the older age group as of 2011

MAP

medication assistance program is a choice you can offer your patient who cannot pay for their medication.

Among older adults living in the community, when and where do most falls occur?

most falls occur during usual activities such as walking. Indoor falls occur most often in the bathroom, bedroom, and kitchen.

Asian Americans

most still practice holistic (naturalistic) medicine and may incorporate this as an adjunct to Western medicine. Use herbal supplements Majority of influence comes from Confucianism (stresses accommodation and avoids confrontation). Follows a naturalistic perspective, defining health and illness as a balance between the individual and the world around the individual. (Strives to be in harmony with the universe in which he or she lives) Basic concept of Chinese medicine is that all things, including the body, are composed of opposing forces called yin and yang. (Health is said to depend on balance of these forces). Chinese medicine focuses on maintaining the yin-yang balance to maintain health and prevent illness. If the balance of yin and yang is broken, it is essential to restore the balance. To regain balance, the belief is that the balance between the internal body organs and the external elements of earth, fire, water, wood, and metal must be adjusted. Treatments may involve - acupuncture, moxibustion (burning of herbal leaves on or near the body), cupping (the use of warmed glass jars to create suction on certain parts of the body), massage, herbal remedies, movement and concentration exercises (tai chi) Some elders may forgo life sustaining treatment because of the principles of ren. Ren is the golden rule of Chines decision making "Do not do to others what you do not want done to yourself".

Explain how you teach an older adult about the assistive technology. See Chapter 9- How older adults learn. Focus on the practical application and benefits of using them. Identify which type of patients are more likely to use assistive devices?

motivation and relevance as two key concepts. Adults expect respect; are autonomous, self-directed, independent learners; are goal oriented; and need to know that what they are learning is relevant and practical. They expect to actively participate in learning and build on previous life events. Adults derive much of their self-identity from past experiences, and nurses should use this knowledge when devising teaching strategies. Fear of failure may also be a concern for this group. Older learners prefer teaching methods that are easy to access and require small investments of time and money. They expect learning to begin immediately through direct hands-on experiences. Older adults with moderate levels of impairment rely more on special equipment and assistive devices, Older persons with multiple impairments that included physical impairments used the greatest number of devices.

Asian Americans - top 5 disparities

new cases of TB, congenital syphilis, no pap test among females > 18, exposure to particulate matter, and carbon monoxide exposure

African Americans - top five health disparities

new cases of gonorrhea, congenital syphilis, new cases of AIDS, and deaths due to HIV infection. The impact of racism has long been considered one of the factors that contribute to decreased longevity and increases of chronic illnesses

Explain whether or not older adults at risk for poor nutrition. If so, explain why. Identify any barriers for older adults in regards to good nutrition

older adults may be at risk for inadequate nutrition because of physiological changes related to organ function declines, which can affect digestion, metabolism, and absorption of nutrients. Additionally, older adults' nutritional intake may be compromised because of the development of poor eating habits related to chewing or swallowing difficulties as well as diminished interest in food resulting from sensory loss (e.g., taste and smell). the costs associated with healthier foods on a limited budget are an issue for many elderly. Cognitive function can be impacted by nutrition; specifically, malnutrition can cause long-term cognitive impairment.

Physiological age-related changes make the older adult more susceptible to adverse drug reactions. There are some key important factors to address when assessing medication and the older adult - Five Rights of Medication Administration

right drug ,right amount, by the right route, at the right times, by the right patient.

African Americans

second larges minority populations. Role of religion and spirituality plays important role in health and wellness. Equate good luck, good fortune, and good health with being right with God. Disease and illness can be thought of as being in disfavor with God. Believe they have less control over their health and well being than God. Illness/disease is part of God's plan. Closer ties with extended families and rely on their close family ties for support. Distrustful of health care personnel because of discrimination in medical care and because most authority figures in health care are not African Americans.

European Americans - top five health disparities

smoking by pregnant women, drug induced deaths, deaths from poisoning, deaths from melanoma, and deaths from COPD before age 45.

Discuss whether an older adult in pain and receiving palliative care should be concerned with addiction

there are many misconceptions about pain in the elderly. • • Pain is a natural outcome of growing old. • • Pain perception or sensitivity decreases with age. • • If an elderly person does not report pain, he or she does not have pain. • • If an elderly patient appears to be asleep or otherwise distracted, he or she does not have pain. • • Potential side effects of opioids make them too dangerous to use to relieve pain in the elderly. • • Alzheimer patients and others with cognitive impairments do not have pain, and their reports of pain are most likely invalid. Nurses need to be able to understand and explain to patients and families the differences among addiction, tolerance, and physical dependence. Fear of addiction should not be a factor in pain control. The findings of several studies have shown that addiction as a result of using opioids for pain relief occurs in less than 1% of patients

Describe importance of discharge med reconciliation

to ensure that accurate information about the patient's medications travels with that patient throughout the health care continuum. The med rec is a formal process of collecting and maintaining a complete and accurate list of a patient's current medications and comparing that list to the physician's admission, transfer, and discharge orders.

Explain the elements of the triple aim of healthcare reform as reflected in the care of older adults.

would identify preventable hospitalizations - Reducing hospitalizations could benefit frail and chronically ill adults and older people who receive long term care because they often experience negative effects of hospitalization, including hospital acquired conditions, morbidity, and loss of functional abilities

Identify alternatives techniques (instead of restraints) to deal with wandering, combative or confused patients.

• • Personal strengthening and rehabilitation program • • Use of personal assistance devices such as hearing aids, visual aids, and mobility devices • • Use of positioning devices such as body and seat cushions or padded furniture • • Safer physical environment design, including removal of obstacles that impede movement, placement of objects and furniture in familiar places, lower beds, and adequate lighting • • Regular attention to physical and personal needs, including toileting, thirst, hunger, socialization, and activities adapted to current ability and former interests • • Design of physical environment for close observation by staff • • Efforts to increase staff awareness of a person's individual needs, including assignment of staff particularly to the person, in an effort to improve function and decrease difficult behaviors • • Living environment designed to promote relaxation and comfort, minimize noise, provide soothing music, and maintain appropriate lighting • • Provision of massage, art, movement activities, and complementary therapies (e.g., Healing Touch, energy work) • • Use of bed, chair, and door alarms to alert to the need for assistance

Guidelines for Introducing Technology and Teaching the Elderly About Its Use

• • The use of technology must be perceived as needed and meaningful, and must be linked to the lifestyle of the person. • • Cautions and disbelief in one's capability may be an obstacle in accepting new technology and must be considered when creating the learning environment. • • A generous amount of time as well as repeated short training sessions should be allowed. • • More stress should be placed on the practical application of the device than on its technical features. • • Only selective, central facts should be presented. • • Mnemonics and cues will favorably affect self-efficacy in handling new products. • • Training sessions should be held in the home or natural meeting places of the elderly. • • The instructor should be well known by the elderly or introduced well in advance of the training. • • The attitudes of the instructors toward the aged must be positive and realistic.