health care team

physicaleffectsofaging

Physical Effects of Aging Throughout a patient's life span, each day brings physical changes that contribute to the health of the individual. In the early, formative years, these changes are centered on development and growth of physical structures within the body. During middle age, the physical changes revolve around maintaining homeostasis for optimal functioning. As a patient ages beyond 65 years, the physical changes begin to shift toward a decline in performance. The specific types of changes and the degree of change are often related to genetics, lifestyle choices, and the effects of chronic illness. For those reasons, some individuals will experience more health problems with aging than others. In the following section, specific information about physiological changes and associated nursing considerations will be explored. Changes in Neurological Functioning As people age, they are less able to process information supplied by both the neurological system and the sensory system. Reflexes slow because of sluggish nerve transmission and synapses. These slower reflexes are often the cause of injuries in elders because they may be unable to react quickly while walking, reaching, or driving. Falls are the most common form of injury related to diminished neurological function. A transient ischemic attack is a temporary decrease in the blood supply to the brain, causing sudden symptoms of dizziness, visual changes, weakness, numbness in one or more limbs, and difficulty swallowing. These attacks are sometimes referred to as "ministrokes," although the patient regains full use and feeling after the attack has passed. They may last a few minutes or a few hours. A cerebrovascular accident (CVA), also known as stroke or brain attack, is also seen more often in the older adult. The cause of a CVA may be either a clot in a blood vessel or a bleeding blood vessel in the brain. When the cause of the CVA is a blood clot, it is referred to as an ischemic stroke; when the cause is a bleeding blood vessel, it is referred to as a hemorrhagic stroke. Either of these events interrupts normal blood flow to an area of the brain, resulting in death of brain tissue. Cerebrovascular accidents are often due to complications of conditions such as hypertension, atrial fibrillation, a diet high in saturated fats, elevated cholesterol levels, and diabetes. Depending on the portion of the brain affected by the stroke, the patient may be mildly to profoundly affected, based on the degree of blockage and the length of time the brain has gone without the necessary oxygen. A left-brain CVA affects motor functioning on the right side of the body, may impair speech, and may cause memory loss. A right-brain CVA affects motor functioning on the left side of the body, can cause visual disturbances, and also may cause memory loss. Cerebrovascular accidents can cause a variety of communication issues, including aphasia, or the inability to speak, and dysphasia, which is difficulty speaking or understanding the spoken word. Behavioral patterns can be affected, without regard to the location of the CVA. Some behavioral changes exhibited after a CVA include depression, tearfulness, personality shifts, and apathy. Often these changes are permanent and can be quite distressing to the family. When you care for a patient who has had a CVA, focus on ways to promote and maintain safety, providing nonjudgmental, compassionate care, and support the family members as they adjust to changes in their loved one. One of the most disturbing changes that may occur after a CVA or other neurological disorders is a decrease in alertness, awareness, and orientation. Confusion, delirium, dementia, and depression are often found in elderly patients, especially after a CVA or with other types of neurological illnesses. Delirium refers to a state of mental confusion that usually is accompanied by illusions and hallucinations. A hallucination is a false perception having no relation to reality; the person may believe that he or she sees, hears, or smells something that is not really present. An illusion is a misinterpretation of sensory stimuli, such as seeing a coat rack but believing it is a human. The patient often is disoriented to time and place. Dementia is a decrease in intellectual functioning eventually resulting in the inability to care for oneself. It occurs gradually over months or years. Table 32-1 describes each of these conditions and the illnesses they often accompany. Due to slowing of neurological processes, communication may be more difficult or take more time than with a younger adult. Speak slowly and be sure to face the patient when speaking to him or her. Allow plenty of time for the patient to respond. If you are in a hurry or feel busy, avoid seeming impatient because this may discourage the patient from attempting to communicate with you. Take the necessary time to engage in conversation with the patient; he or she just might have something important to say. Table 32-2 provides information regarding the results of body system deficits, including neurological deficits, and the recommended nursing actions for these concerns. Supervision/Delegation Connection Caring for Confused Elderly Patients In some states, the RN or LPN/LVN can delegate certain tasks to UAPs when caring for confused elderly patients. These tasks may include performing hygiene routines, assisting with activities of daily living, transferring between bed and chair, answering call lights promptly, providing adequate fluid intake and nutrition, and assisting the RN or LPN/LVN in maintaining environmental safety. If you choose to delegate when a patient is confused, be available to help the UAP because personal care may require two people under such circumstances. Alzheimer's Disease The most common type of dementia is seen in patients with Alzheimer's disease, which is strongly associated with aging. The diagnosis of Alzheimer's disease is based on symptoms because the only way this disease can be confirmed is by finding the characteristic neurofibrillary tangles in the brain on autopsy. It is seen most commonly in middle-old and old-old adults, but it has occurred in adults as young as 30 years. Patients with Alzheimer's disease slowly withdraw from family and social interaction. They develop confusion that increases in severity until they reach a point where they do not recognize their own family members. They often wander at night and sleep during the day. Eventually they are unable to walk and speak, making sounds rather than words. Patients with advanced Alzheimer's disease require complete care and are totally dependent on others. When family members are the primary caregivers, they may become overwhelmed; when this occurs, they, along with the patient, will need care and support.

safety

This patient is terminally ill and has been bathed, dressed, and made comfortable by the nursing staff. (From Williams LS, Hopper PD. Understanding Medical-Surgical Nursing. 4th ed. Philadelphia: FA Davis; 2011.) When you care for older patients who are dealing with loss and grief, you can include the following when planning and delivering nursing care: • Refer to support groups: Most communities have numerous support groups, which focus on different types of losses. They include those designed to support surviving spouses, those who have lost children, and those who have experienced any type of loss. • Educate about the importance of proper nutrition and exercise: Older adults, especially those who live alone, may lose interest in food during an episode of loss and grief. Explain the importance of proper nutrition to keep the body strong and to help prevent new illnesses or worsening existing conditions. Exercise helps relieve stress and tension, and can provide a time for focusing on something other than grief. • Encourage rest: Because the grieving process can be exhausting, it is important for older adults to have the opportunity to rest when needed. • Help find comfort and meaning: Sometimes this is as simple as sitting with the patient and allowing him or her to express feelings about the loss just experienced. There is no magic formula for helping the patient find comfort, but the presence of another human being who allows him or her to express feelings can prove to be quite comforting, particularly if the older adult has lost a close friend or spouse. Chapter 10 provides additional information about ways to help grieving patients. • Encourage spirituality, if the patient desires: Older adults may find comfort in their spiritual beliefs during times of loss. You may contact an appropriate person to assist the patient, such as a pastor, chaplain, priest, or shaman to assist them. Figure 32-4 shows an elderly person practicing his faith. • Allow the patient to grieve: Provide privacy or sit in silence with the patient, as indicated, to allow the patient time to grieve. Recognize that each person may grieve differently, so be supportive and nonjudgmental during this time. Figure 32-4 To meet the spiritual needs of elderly patients, provide opportunities for them to practice their faith. (Getty Images.) Safety From Scams and Crime Older adults are considered easy prey because they are less skeptical about solicitations for money than younger individuals, making them frequent victims of those trying to defraud them of money. It is not uncommon for such scams and crimes to take place over the telephone. The older adult does not know the caller, and sometimes it is easy for scammers to talk an elder into giving them credit card numbers or other identifying information, which they then use to defraud him or her. Because elderly people are often homebound and socially isolated, callers have an easy time gaining their trust, often because the callers are personable and sound official. Safety: Older adults should be cautioned about giving personal information over the telephone, via the mail, or over the Internet, because so many of these schemes are indeed ways to pilfer money from unsuspecting people. Other scams involve people who come to an older adult's home and represent themselves as repairmen or utility workers. These people often are dressed for the part, and, when they gain entry into the home, they physically harm and rob the elderly person. Or they may give the false impression of having supplied the appropriate service when, in fact, they only completed small portions of the work or performed shoddy work. The elderly person then pays exorbitant amounts of money to these people, who leave false contact information with the elderly individual and then disappear. Safety: Caution older adults not to allow anyone into their home whom they are not expecting and to always ask for identification before allowing an expected worker in. It is sometimes helpful if the elderly individual will consult a trusted family member or friend who might assist in determining the legitimacy of workers who are being considered for hire. However, many elderly individuals are struggling to maintain their sense of independence and are resistant to others helping them make their decisions. Elder Abuse It may come as a surprise to most to learn that, according to the National Center on Elder Abuse, it is estimated that between one and two million seniors have been injured, exploited, or otherwise mistreated by a caregiver. This type of abuse can take place in many forms: neglect, which means that the caretaker has omitted providing basic necessary care, such as food or fluids, hygiene, or a safe environment; psychological abuse, which entails manipulation or mental cruelty; physical abuse, which involves any kind of physical harm done to the patient; and exploitation, which involves using the older adult for personal gain, such as gaining access to the older adult's bank account and using it without his or her knowledge. Physical abuse is more recognized because of the outward signs that this type of abuse leaves behind. Be alert for these findings that could suggest abuse: • Excessive bruises in unexpected places: This could be the caregiver's attempt to hide abuse by hurting the victim in places that would not normally be visible. • Bruises in multiple stages of healing: This finding could potentially indicate that the older adult has been abused on an ongoing basis. When bruises are found in multiple stages of healing, it could be an indicator of infrequent abuse that occurs at different times or of frequent and varying kinds of abuse. • Bite marks: Although less common than bruises and lacerations, bite marks may be found and be indicative of abuse. • Burns: Burns in varying locations over the body often are indicators of abuse. The more frequent types of abusive burns come from cigarettes, which produce small round burns. When found, they are commonly seen on the palms of the hands or the soles of the feet, or on the abdomen. • Lacerations: Like burns, the finding of multiple lacerations, particularly in various stages of healing, may indicate that the older adult is living in an unsafe environment where he or she is repeatedly brushing against objects that cut, or that he or she is being purposely cut by a caregiver. • Fractures or dislocations: Although there are no classic patterns of fractures that indicate elder abuse, keep in mind that repeated or multiple fractures or dislocations may be cause for concern. • Sedation: Patients who are sedated may have been overdosed on medication. A caregiver may knowingly administer too much medication as a way to manage an elderly person, or a caregiver may accidentally be administering too much of a certain medication. • Dehydration or malnutrition: These may be signs of poor dietary intake and may not indicate abuse. However, continued or repeated admissions for dehydration or malnutrition may indicate that the patient is not being provided with proper nutritional intake. • Excessively poor hygiene or unsuitable clothing: This finding may indicate that the patient is not being cared for appropriately. Some elderly people are unable to see that their clothing is not clean and may show a lack of interest in personal hygiene. Therefore, be sure to investigate the situation before assuming that abuse is taking place. Safety: If elder abuse of any type is suspected, it should be reported immediately to the proper state authorities for investigation. Financial Concerns While many people are ready to retire at age 62 or 65 years, others prefer to remain in the workforce until age 70 years or older. As they contemplate this change in work status, older people may express concerns about how they will provide for themselves and whether they will have enough money in the future when their income is fixed. Between the financial implications of older age and the physical changes that may take place, older adults may also have concerns about living arrangements. Many people wonder if they will have enough money to pay for a nursing home should they ever have to be admitted to one. Although you cannot solve these problems, you can provide empathetic, therapeutic listening and refer the patient to appropriate resources for assistance. These resources may include social workers, social service agencies, the local Area Agency on Aging, and other senior assistive facilities. Positive Aspects of Aging In this chapter, we have discussed all the changes that aging brings, both physical and psychosocial. However, with those changes, aging also brings wisdom and insight. It is often within this stage of life that people have so much knowledge to share with younger generations. Over the years, they have developed social skills, successfully raised families, excelled at a trade or business, learned from their own mistakes, experienced many things that others have yet to experience, and mastered concepts that younger adults have not yet grasped. They can utilize these rich pieces of knowledge as grandparents, civic leaders, volunteers, church workers, neighbors, and friends. Be respectful of this special time in the life of an older adult, and work to promote self-esteem as physical, psychosocial, and spiritual changes take place. Avoid stereotypes and meet each patient where he or she is in the aging process, and you can effectively care for the patient's needs personally and professionally while promoting dignity in the aging years. Figure 32-5 shows how helping an elderly person to be well groomed can promote dignity.

Population

s Changes in Reproductive Functioning Older adults experience a normal decrease in hormone levels as they age. Men will experience a decline in testosterone, while women will experience a decline in estrogen. As this happens, men will still produce sperm, although they might not be as viable as sperm produced in younger years. Women will have gone through menopause during middle adulthood into early older age, which eliminates the possibility of childbearing. This decrease in hormonal activity can change the older adult's sexual drive. Some older adults will gravitate toward less frequent sexual activity, while others will maintain an active sex life. Avoid stereotyping and assuming that seniors are uninterested in sexual relationships. Reassure patients about their own sexual needs and provide for privacy, caring for patients in a nonjudgmental fashion. Erectile dysfunction (ED) is a condition in which men cannot achieve or maintain an erection. Medical disorders such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurological disease can cause ED. Effective medications are available to treat ED. It is most important for seniors to be educated about ways in which to protect themselves when they engage in sexual activity. The current generation of seniors did not grow up with the fear of sexually transmitted diseases, including HIV, AIDS, and hepatitis, so they may have questions about prevention. Table 32-2 provides information about reproductive system concerns and the recommended nursing actions for these concerns. Changes in Musculoskeletal and Integumentary Functioning As patients age, increased bone loss and muscle mass loss increase the risk for injury. As calcium is lost from the bones because of decreased absorption (and estrogen loss that takes place in women), osteoporosis can develop. Figure 32-2 shows a resident with a musculoskeletal condition that requires the use of a wheelchair. A decrease in muscle fibers and motor neurons causes a decrease in muscle mass and strength. Skin becomes less elastic and more prone to drying, nails thicken, and the skin bruises easily. Because of these changes and the changes related to diabetes, pay particular attention to the feet of patients with diabetes. They are less likely to be aware of dry, cracked skin on their heels, which can lead to an infection. They also may be unaware of a developing foot ulcer due to compromised blood flow that is often associated with diabetes. Figure 32-2 A patient with musculoskeletal disorders uses a wheelchair for mobility. (From Polan E, Taylor D. Journey Across the Life Span: Human Development and Health Promotion. 4th ed. Philadelphia: FA Davis; 2010.) The loss of subcutaneous fat and the decrease in sweat gland density over time change the older adult's ability to thermoregulate, meaning that they may chill more often than other individuals. Table 32-2 provides information regarding musculoskeletal and integumentary system deficits and the recommended nursing actions for these concerns. Knowledge Connection What might you teach an older adult about preventing UTIs? What would you teach an older adult about preventing osteoporosis? Psychosocial Problems of Aging When you perform an assessment on an older adult, keep in mind the numerous psychosocial concerns that he or she may have. Some of these were discussed earlier in this chapter, such as the loss of connection with loved ones that occurs in different types of dementia. Other concerns of older adults and their caregivers include: • Fears about the dying process, as some people may struggle with spiritual beliefs • Loss and grief as friends and family die or leave • Safety concerns, including scams and crimes • Elder abuse by caregivers • Financial concerns regarding retirement and living arrangements Loss, Grief, and Dying It is a common misconception that, because a person is older, he or she is consumed with thoughts of death. Like most of us, thoughts of mortality do arise and are more prevalent if we receive a diagnosis of a terminal or untreatable disease. Figure 32-3 shows an elderly resident toward the end of her life. Older people also may feel their own mortality more strongly because of losing friends and family members to death with increasing frequency. One middle-old couple moved to a retirement center and made many new friends, but in the first year of residency, approximately half of them died. While other people moved in and took their places, this change was difficult for the couple. Chapter 10 discusses the stages of grieving and therapeutic approaches you can use with your patients who are dealing with grief. Chapter 8 provides information regarding the spiritual aspect of your nursing care.

pulmonary rehab

program of education and exercise classes that teach patients about their lungs, how to exercise and perform activities with less shortness of breath, and how to live better with a lung condition. The health-care team for pulmonary rehabilitation includes a pulmonologist (physician who specializes in diseases and treatments of the lungs), nurses, respiratory therapists, and respiratory assistants. Pulmonary rehabilitation is provided through an outpatient setting of a hospital or at a freestanding facility.

fitzpatricksrhythmmodel

A nursing theory that deals with health and wellness is Dr. Joyce Fitzpatrick's rhythm model. One of the major concepts of Fitzpatrick's theory is that of wellness-illness. Nursing is rooted in the promotion of wellness practices, the attentive treatment of those who are acutely or chronically ill or dying, and the restorative care of people during convalescence and rehabilitation. In this model, health is a dynamic state that results from the interaction of a person and his or her environment. A person's state of health can vary from wellness to illness, disease, or dysfunction, and it changes continuously throughout the person's life span.

examples of residential care facilities

A client may live in a variety of residential care settings. Each provides a different level of assistance. • Long-term care facilities: Also called nursing homes or convalescent homes, these facilities are where residents often live for many years. Nursing care is provided around the clock for the residents in these facilities • Assisted living facilities: These facilities provide less nursing care than that found in long-term care facilities. Residents are assisted with medications and personal care such as bathing and dressing. Meals are provided, and a choice of activities may be available. • Independent living facilities: These facilities do not provide nursing care. They generally have staff available around the clock to respond to urgent situations by contacting emergency medical services for the residents. Meals usually are available, as well as transportation and activities

acute care hospital or medical center

Acute care hospitals provide emergency care, surgeries, inpatient care, diagnostic testing, and usually some types of outpatient care. Staff is composed of a variety of doctors, nurses, assistants, therapists, laboratory workers, and other medical personnel. Rural hospitals may be smaller, with fewer departments and less staff than their larger city counterparts. Regardless of size or location, when a person is ill or injured, he or she generally seeks care at the closest hospital.

self pay

Although it is the goal of the Affordable Care Act that all people in the United States will have health insurance, there may be some who do not have it and must pay for their health care on their own. They may prefer to pay the nominal fine compared with the cost of health insurance, or they may be unable to afford the least expensive insurance on the exchange. Many health-care providers will offer discounts to those who must pay for their own care, and most will require a payment plan to pay a fixed amount monthly on the bill. Some physicians are opting for a self-pay option called concierge medicine. In this model, physicians often do not accept any form of insurance. Instead, the patient pays a yearly fee, often $2000 or $3000, to have full access to their physician. In return for that fee, the physician is available by phone 24 hours per day, 7 days per week. The patient is seen quickly when the need arises. The patient also pays a visit fee to the physician, which varies according to what is done and whether the physician accepts insurance. This type of care often can prevent the need for hospitalization by allowing early intervention in an acute illness or complication of a chronic illness.

ancillary staff

Ancillary Staff Pharmacist Pharmacy Technician Pharmacist distributes prescription medications; advises patients and prescribers on the selection, dosages, interactions, and side effects of medications Pharmacy technician assists pharmacist by helping to prepare prescribed medications, answering phones, and stocking shelves Registered Dietitian (RD) Dietary Technician RD plans regular menus and develops special menus to meet the dietary needs of patients; works with physicians to meet special dietary needs; and instructs patients on special diets Dietary Technician assists the RD by distributing and picking up selective menus and monitoring patient food intake Medical Social Worker Public Health Social Worker Provides psychosocial support to patients, families, or vulnerable populations; advises caregivers; counsels patients; plans for patients' needs after discharge; and arranges for needed care such as home health care Chaplain Provides spiritual care for patients in hospitals and hospice settings; meets spiritual needs of families and patients when diagnosis is terminal or when death occurs; provides spiritual care for hospital staff

Assisted living facilities

Assisted living services include 24-hour protective oversight, food, shelter, and a range of services that promote the quality of life of the individual. The health-care team in an assisted living facility may consist of one or more registered nurses (RNs), several license practical/vocational nurses (LPNs/LVNs), and numerous nursing assistants and certified medication aides. In some assisted living facilities, a nurse is not on the premises 24 hours per day, but one is available by telephone. Therapies such as physical, occupational, and speech therapies may be available but are not part of the facilities' regular services. These services are generally provided by contracted home health-care agencies.

changes in sensory function

Changes in Cardiovascular Functioning As patients age, the heart muscle loses elasticity, the blood vessels narrow as arteries collect fatty deposits, and peripheral pulses are less palpable. Circulation is decreased, resulting in patient complaints of feeling cold, especially at bath time. These patients require a warmer room and warmer clothes than do younger people. These circulatory changes may occur without the patient's awareness, which puts the person at high risk for developing conditions such as coronary artery disease, hypertension, high cholesterol levels, myocardial infarction (also known as heart attack), or peripheral vascular disease. It is estimated that approximately two-thirds of individuals older than 65 years have coronary artery disease. Table 32-2 provides information regarding the cardiovascular changes that occur with aging and the recommended nursing actions for these concerns. Changes in Respiratory Functioning In an aging patient, you would expect lung elasticity to be decreased. As with many body systems, the flexibility of the normally elastic lung tissue is reduced over time. The alveoli do not expand fully, which increases the risk for pneumonia, bronchitis, and complications of underlying chronic pulmonary disease. Older adults are also more vulnerable to infections, particularly respiratory infection due to decreased immune function. Therefore, be sure to educate patients about ways in which to protect themselves from easily contracted infections. Table 32-2 provides information about ways to help patients protect themselves from respiratory illnesses. Changes in Gastrointestinal Functioning As peristalsis slows in the older adult, the cycle of food digestion slows, which can lead to poor appetite and decreased food intake. This may then result in malnutrition, weight loss, and an overall decrease in immune function. It is very important that you investigate the cause of a loss of more than a few pounds or kilograms in patients who are not trying to lose weight. Constipation may result from numerous factors. Many medications list constipation as a side effect. As patients grow older, their lack of activity may slow down the entire gastrointestinal functioning, including evacuation. Aging can affect peristalsis, increasing the amount of time that feces remains in the large intestine, causing more water to be absorbed, leaving the stool dry and hard. Some older adults become very focused on the frequency of their bowel movements and become distressed easily if constipation occurs. Administer ordered medications such as stool softeners and laxatives to help prevent this problem. Xerostomia is the medical term for an excessively dry mouth. This is a common complaint of older adults, as many medications can dry normal secretions. The cells in the salivary glands, just as in the rest of the body, diminish in size and number, which compounds this problem. Table 32-2 provides information regarding deficits of gastrointestinal functioning and the recommended nursing actions for these concerns. Changes in Endocrine and Genitourinary Functioning As people age, the function of the pancreas decreases, which can lead to poorly controlled diabetes. Metabolism can slow, which means weight can increase. If patients are not able to exercise because of impaired mobility, the extra weight can affect their endurance. As a complication of diabetes or other diseases, older adults may experience changes in renal function, leading to incomplete waste removal due to decreased efficiency of the filtering mechanism of the kidneys. This generally occurs gradually and eventually may lead to kidney failure. Figure 32-1 shows an elderly patient with renal changes. With aging, the capacity of the bladder decreases because of loss of muscle tone. The bladder cannot hold as much urine as that of a younger adult, and older persons must go to the bathroom to empty the bladder more frequently. They often experience nocturia, which puts them at risk for falls and injuries when they are up at night. In addition, older adults are more at risk for developing UTIs due to more concentrated urine and decreased function of the immune response. Without proper attention, patients can develop urinary sepsis, a condition that warrants hospitalization and often is fatal. Table 32-2 provides information regarding endocrine and genitourinary system deficits and the recommended nursing actions for these concerns.

physical signs of aging

Changes in Endocrine and Genitourinary Functioning As people age, the function of the pancreas decreases, which can lead to poorly controlled diabetes. Metabolism can slow, which means weight can increase. If patients are not able to exercise because of impaired mobility, the extra weight can affect their endurance. As a complication of diabetes or other diseases, older adults may experience changes in renal function, leading to incomplete waste removal due to decreased efficiency of the filtering mechanism of the kidneys. This generally occurs gradually and eventually may lead to kidney failure. Figure 32-1 shows an elderly patient with renal changes. With aging, the capacity of the bladder decreases because of loss of muscle tone. The bladder cannot hold as much urine as that of a younger adult, and older persons must go to the bathroom to empty the bladder more frequently. They often experience nocturia, which puts them at risk for falls and injuries when they are up at night. In addition, older adults are more at risk for developing UTIs due to more concentrated urine and decreased function of the immune response. Without proper attention, patients can develop urinary sepsis, a condition that warrants hospitalization and often is fatal. Table 32-2 provides information regarding endocrine and genitourinary system deficits and the recommended nursing actions for these concerns. Anatomy and Physiology Connection Metabolization and Elimination of Medications Most medications are metabolized and eliminated from the body via the hepatic and renal systems. After a medication is digested, it is absorbed into the bloodstream, where it can be transported through the portal vein to the liver, where most medications are metabolized, or broken down for use, leaving what is known as by-products or end products. The medication is then carried by the hepatic vein to the heart, where it is pumped out and circulated to the target organs. However, the drug is carried not only to the target organs but through the entire body and eventually back to the liver, where any remaining drug can be processed further. The end products of medications are filtered and removed from the blood as it flows through the kidneys and then are excreted in the urine. If the liver or kidneys are not able to remove the toxins because of disease or impairment, they remain in the blood and circulate through the body. Essentially, this can lead to cumulative effects similar to a drug overdose. The by-products of metabolized medication are sometimes toxic to the liver. When the liver is exposed to excessively high levels or constant levels of a hepatotoxic drug, the liver can be seriously or even fatally damaged. An example of a drug that is toxic to the liver is acetaminophen, more commonly known as Tylenol. Many medications carry warnings that patients must have regular liver and kidney function testing while they are taking the drugs to detect damage to those organs that remove the medication from the body. Figure 32-1 A patient with kidney failure does not necessarily look ill but experiences lack of energy, anemia, and elevated BUN and creatinine levels. (From Polan E, Taylor D. Journey Across the Life Span: Human Development and Health Promotion. 4th ed. Philadelphia: FA Davis; 2010.) Changes in Reproductive Functioning Older adults experience a normal decrease in hormone levels as they age. Men will experience a decline in testosterone, while women will experience a decline in estrogen. As this happens, men will still produce sperm, although they might not be as viable as sperm produced in younger years. Women will have gone through menopause during middle adulthood into early older age, which eliminates the possibility of childbearing. This decrease in hormonal activity can change the older adult's sexual drive. Some older adults will gravitate toward less frequent sexual activity, while others will maintain an active sex life. Avoid stereotyping and assuming that seniors are uninterested in sexual relationships. Reassure patients about their own sexual needs and provide for privacy, caring for patients in a nonjudgmental fashion. Erectile dysfunction (ED) is a condition in which men cannot achieve or maintain an erection. Medical disorders such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurological disease can cause ED. Effective medications are available to treat ED. It is most important for seniors to be educated about ways in which to protect themselves when they engage in sexual activity. The current generation of seniors did not grow up with the fear of sexually transmitted diseases, including HIV, AIDS, and hepatitis, so they may have questions about prevention. Table 32-2 provides information about reproductive system concerns and the recommended nursing actions for these concerns. Changes in Musculoskeletal and Integumentary Functioning As patients age, increased bone loss and muscle mass loss increase the risk for injury. As calcium is lost from the bones because of decreased absorption (and estrogen loss that takes place in women), osteoporosis can develop. Figure 32-2 shows a resident with a musculoskeletal condition that requires the use of a wheelchair. A decrease in muscle fibers and motor neurons causes a decrease in muscle mass and strength. Skin becomes less elastic and more prone to drying, nails thicken, and the skin bruises easily. Because of these changes and the changes related to diabetes, pay particular attention to the feet of patients with diabetes. They are less likely to be aware of dry, cracked skin on their heels, which can lead to an infection. They also may be unaware of a developing foot ulcer due to compromised blood flow that is often associated with diabetes. Figure 32-2 A patient with musculoskeletal disorders uses a wheelchair for mobility. The loss of subcutaneous fat and the decrease in sweat gland density over time change the older adult's ability to thermoregulate, meaning that they may chill more often than other individuals. Table 32-2 provides information regarding musculoskeletal and integumentary system deficits and the recommended nursing actions for these concerns.

changes in orientation

Changes in Orientation Disorder Description Reversible? Associated Disorders and Conditions Confusion Cannot think clearly; considered a cognitive impairment Sometimes Drug side effect Cerebrovascular accident Trauma Metabolic disorders Alzheimer's disease and other dementias Excessive stimuli from around-the-clock nursing care in critical care unit and lights always on Hypoxia Delirium State of heightened awareness; hallucinations and vivid dreams present; often has emotional outbursts Yes Drug side effect Drug intoxication Drug or alcohol withdrawal Febrile state Hypoxia Dementia Deterioration of cognitive functioning without a disturbance in consciousness No Alzheimer's disease Cerebrovascular accident Head injury Depression Alteration in emotional state marked by intense sadness or despondency, hopelessness, powerlessness Yes After a loss of loved one, relationship, home, independence, or financial security Coupled with certain medications Lifestyle changes Table 32-2 Results of Body System Deficits and Recommended Nursing Actions Results of Body System Deficits Recommended Nursing Actions Neurological System Falls and broken bones • Assess patient's safety in the environment. • Institute ways to improve safety. Burns and other accidental injuries • Check water temperature often during bathing. • Check on patient frequently. • Provide for sitters as needed and available. • Always explain what you are about to do before doing it. • Use a calming tone of voice when interacting. • Leave the light on at night if needed. Self-inflicted injuries • Assess risk for suicide or self-harm. • Refer to the physician and appropriate mental health agencies. Confusion • Recommend Alzheimer's disease support groups. • Refer to home health services and Alzheimer's disease residential facilities as appropriate. • Encourage respite services for family members taking care of confused patients. Sensory System Decreased sensation • Assess feet for injury, sores, or ingrown toenails, and encourage follow-up with the physician. • Safety: Monitor the temperature of the bath water to prevent burns. Poor vision • Encourage patients to have regular eye examinations. • Safety: Provide adequate lighting for reading and moving about the room. • Safety: Provide a nightlight as needed. • Safety: Keep pathways clear of objects. • Provide magnifiers for reading. Impaired hearing • Encourage regular hearing evaluations. • Teach patients about availability of systems that can activate flashing lights for smoke detectors, ringing telephones, and doorbells. Cardiovascular System Elevated cholesterol and blood pressure • Encourage a heart-healthy diet. • Assess blood pressure every 8 hours or more frequently. Decreased peripheral circulation • Assess peripheral pulses for weakness or absence; assess for slow capillary refill, decreased warmth of hands or feet, and pallor of extremities. • Assess for environmental temperature comfort and provide extra blankets as needed; raise room temperature prior to bathing to prevent chilling. Decreased cardiac output • Assess lungs for adventitious breath sounds and auscultate heart for irregular rhythm or indistinct heart sounds every 8 hours. • Assess for shortness of breath with exertion, distended neck veins, pallor, bounding or thready radial pulse, tachypnea, pedal edema, weak or absent peripheral pulses; cold or pale extremities; confusion or restlessness; decreased level of consciousness; decreased urinary output. • Encourage regular, moderate exercise. Respiratory System Chronic respiratory conditions • Encourage patients to wash hands frequently and correctly, as well as to use hand sanitizer if they are unable to wash with soap and water. • Instruct patients to stay 3 to 6 feet away from others who are ill with a respiratory illness. • Encourage compliance with respiratory medications and antibiotics. • Encourage patients to get flu and pneumonia vaccines. • Assure that bedridden patients are repositioned every 2 hours to prevent pneumonia. • Assess for fever, tachycardia, tachypnea; assess breath sounds, noting decreased, absent, or adventitious sounds. Inadequate O2 supply to meet body demands during activity • Plan nursing care in a manner to provide frequent rest periods. • Group nursing tasks together in short sessions to avoid constant interruption. • Observe for increases in respirations during activity. • Assess for pallor and cyanosis during activity. • Assess oxygen saturation level; apply and maintain supplemental oxygen as needed and ordered. Gastrointestinal System Decreased peristalsis • Encourage high-fiber foods, high fluid intake, activity, and appropriate use of laxatives and stool softeners. Dryness of the mouth • Perform mouth care every 8 hours or more often as needed. Impaired sense of taste • Encourage balanced, nutritional meals of foods the patient likes to eat. Endocrine System Impaired blood sugar regulation • Encourage balanced, nutritional meals and regular exercise. • Assess finger stick blood sugar as ordered and administer ordered antidiabetic medications. Reproductive System Decreased estrogen production in females • Educate about lubrication products and locally applied estrogen creams to decrease vaginal dryness. Decreased circulation to genitalia in males • Encourage discussion of erectile dysfunction if it is a problem. • Discuss blood sugar and blood pressure control, which can help decrease development of erectile dysfunction. Genitourinary System Impaired emptying of bladder • Scan the bladder to detect urinary retention. • Assess for signs and symptoms of urinary tract infection (UTI): burning during urination, urgency, frequency, cloudy urine, and a foul odor to urine. • Encourage fluid intake of liquids the patient likes to drink. Decreased renal function • Assess intake and output every 8 hours; observe for decreasing urine production, making certain that kidneys are producing the minimum of 30 mL/hr. Assess laboratory results for renal function: blood urea nitrogen (BUN), creatinine, glomerular filtration rate (GFR). • Assess intake and output every 8 hours; observe for decreasing urine production, making certain that kidneys are producing the minimum of 30 mL/hr. Incontinence • Implement bladder training when appropriate; assess for wet bed every hour; change wet linens as soon as detected; keep perineum and buttocks clean and dry. • If using adult waterproof underwear, avoid calling them diapers. • Treat incontinent patients with respect. Musculoskeletal System Osteoporosis • Encourage weight-bearing exercise. • Encourage increased calcium intake in foods and supplements. • Encourage compliance with other medications for bone strength. • Encourage the installation and use of handrails in tubs and around toilets in the patient's home. • Encourage the use of commercial "emergency help signal devices" that can be worn around the neck and activated when the patient falls or becomes seriously ill. Contractures • Perform range-of-motion exercises at least once or twice per day if a patient is unable to ambulate. • Encourage neck, arm, and leg exercises that can be performed while sitting in a chair. • Use hand rolls to prevent contractures of hands. • Maintain proper body alignment both in bed and when sitting in a chair. • Encourage the patient to perform as much self-care as able. Integumentary System Skin easily damaged • Encourage protection of skin, such as wearing only closed-toed shoes. • Assess and cover all skin tears or open areas. • Apply creams and lotions to prevent cracking of skin. Increased capillary fragility • Assess all injuries, even seemingly minor ones. • Ensure that bleeding is controlled and stopped. • Be careful to avoid bumping or scraping the patient's arms and legs on bed rails, bed frames, wheelchairs, or chair legs. • Be gentle when handling the patient; when applying tape to the skin, use the least amount that will accomplish your goal. • Report bleeding gums. Decreased circulation to skin and underlying tissue • Turn immobile patients every 2 hours, and encourage frequent position changes in patients who can turn themselves. • Place pillows between knees and ankles when in side-lying positions. • Keep sheets as wrinkle-free as possible. • Avoid allowing the patient to lay in a wet bed. • Change linens frequently. • Position heels so they do not constantly rest on the bed. • Use sheepskin elbow and heel protectors as needed. • Provide skin care several times per day if the patient is bedridden. • Assess pressure points for erythema at least every 4 hours, sometimes as often as every 2 hours. • Encourage adequate fluids and nutrition; provide protein supplements if needed. It is difficult for family members to watch a loved one who has developed multiple medical problems "slip away" from them, particularly when one of the medical concerns is Alzheimer's disease or another form of dementia. Family members often describe this process as taking care of someone they feel like they do not know because the cognitive changes seen in dementia seem to rob the patient of distinct personality features. While the nursing care for patients with dementia often focuses on maintenance of safety and assistance with activities of daily living, the care given to the caregiver is just as important and focuses on preventing burnout. Real-World Connection Alzheimer's Disease A 75-year-old woman was caring for her elderly husband who had multiple illnesses as well as Alzheimer's disease. She was devoted to him and was his sole caregiver. Eventually, hospice was called in to provide additional in-home care. His wife struggled with watching his decline and accepting help with his care. She felt as though she was losing her husband and best friend as he became more and more withdrawn. The hospice nurse answered her questions honestly and allowed her to verbalize her sadness regarding the fact that he would not get better. As her husband's physical and neurological function continued to decline, it was suggested that he be moved to a skilled nursing facility. This was extremely difficult for his wife to allow because she kept wondering if she could do more to be able to keep him home. Once again, the hospice nurse helped her see the reality of the situation. Using criteria recommended by the Alzheimer's Association (Box 32-1), the nurse assessed the wife's stress level and risk for burnout. The nurse also helped her understand that she was becoming overwhelmed, losing weight and sleep, and unable to keep her husband safe in the home setting. The nurse reassured the wife that he would be safe and attended to 24 hours a day, 7 days a week, at the skilled nursing facility. Three weeks after his admission to the facility, he passed away peacefully, and his wife was grateful for the care he was given prior to his death. Although her husband did not survive, she was at peace with her decision and valued those last days with him because she could completely focus on being with him rather than trying to complete the innumerable tasks related to his care. When you care for patients and family members in similar situations, it is important for you to help the family realize that it is not a sign of failure, but a sign of strength, to tap into the help available for both them and their loved one. Signs of Caregiver Burnout When you are caring for a patient who has family members or friends involved in his or her care, it is important to pay attention for the signs of caregiver burnout. Even though caregivers are not necessarily sick, giving care to a loved one can be a very stressful experience. Ask these questions when assessing whether or not a caregiver is experiencing burnout: • Does the caregiver feel that he or she must be the exclusive care provider? • Does the caregiver feel that he or she is withdrawing from other friends, family, or activities because of the care he or she must provide for the loved one? • Does the caregiver worry about the safety of the loved one? • Is the caregiver anxious about finances and making health-care decisions for his or her loved one? • Is the caregiver denying the impact of the disease and its effects on the family? • Is the caregiver experiencing grief or sadness that the relationship with the loved one is deteriorating? • Does the caregiver get frustrated or angry when the loved one does not listen? • Is the caregiver experiencing personal health problems in addition to caring for the loved one?

changesinorientation

Changes in Orientation Disorder Description Reversible? Associated Disorders and Conditions Confusion Cannot think clearly; considered a cognitive impairment Sometimes Drug side effect Cerebrovascular accident Trauma Metabolic disorders Alzheimer's disease and other dementias Excessive stimuli from around-the-clock nursing care in critical care unit and lights always on Hypoxia Delirium State of heightened awareness; hallucinations and vivid dreams present; often has emotional outbursts Yes Drug side effect Drug intoxication Drug or alcohol withdrawal Febrile state Hypoxia Dementia Deterioration of cognitive functioning without a disturbance in consciousness No Alzheimer's disease Cerebrovascular accident Head injury Depression Alteration in emotional state marked by intense sadness or despondency, hopelessness, powerlessness Yes After a loss of loved one, relationship, home, independence, or financial security Coupled with certain medications Lifestyle changes Table 32-2 Results of Body System Deficits and Recommended Nursing Actions Results of Body System Deficits Recommended Nursing Actions Neurological System Falls and broken bones • Assess patient's safety in the environment. • Institute ways to improve safety. Burns and other accidental injuries • Check water temperature often during bathing. • Check on patient frequently. • Provide for sitters as needed and available. • Always explain what you are about to do before doing it. • Use a calming tone of voice when interacting. • Leave the light on at night if needed. Self-inflicted injuries • Assess risk for suicide or self-harm. • Refer to the physician and appropriate mental health agencies. Confusion • Recommend Alzheimer's disease support groups. • Refer to home health services and Alzheimer's disease residential facilities as appropriate. • Encourage respite services for family members taking care of confused patients. Sensory System Decreased sensation • Assess feet for injury, sores, or ingrown toenails, and encourage follow-up with the physician. • Safety: Monitor the temperature of the bath water to prevent burns. Poor vision • Encourage patients to have regular eye examinations. • Safety: Provide adequate lighting for reading and moving about the room. • Safety: Provide a nightlight as needed. • Safety: Keep pathways clear of objects. • Provide magnifiers for reading. Impaired hearing • Encourage regular hearing evaluations. • Teach patients about availability of systems that can activate flashing lights for smoke detectors, ringing telephones, and doorbells. Cardiovascular System Elevated cholesterol and blood pressure • Encourage a heart-healthy diet. • Assess blood pressure every 8 hours or more frequently. Decreased peripheral circulation • Assess peripheral pulses for weakness or absence; assess for slow capillary refill, decreased warmth of hands or feet, and pallor of extremities. • Assess for environmental temperature comfort and provide extra blankets as needed; raise room temperature prior to bathing to prevent chilling. Decreased cardiac output • Assess lungs for adventitious breath sounds and auscultate heart for irregular rhythm or indistinct heart sounds every 8 hours. • Assess for shortness of breath with exertion, distended neck veins, pallor, bounding or thready radial pulse, tachypnea, pedal edema, weak or absent peripheral pulses; cold or pale extremities; confusion or restlessness; decreased level of consciousness; decreased urinary output. • Encourage regular, moderate exercise. Respiratory System Chronic respiratory conditions • Encourage patients to wash hands frequently and correctly, as well as to use hand sanitizer if they are unable to wash with soap and water. • Instruct patients to stay 3 to 6 feet away from others who are ill with a respiratory illness. • Encourage compliance with respiratory medications and antibiotics. • Encourage patients to get flu and pneumonia vaccines. • Assure that bedridden patients are repositioned every 2 hours to prevent pneumonia. • Assess for fever, tachycardia, tachypnea; assess breath sounds, noting decreased, absent, or adventitious sounds. Inadequate O2 supply to meet body demands during activity • Plan nursing care in a manner to provide frequent rest periods. • Group nursing tasks together in short sessions to avoid constant interruption. • Observe for increases in respirations during activity. • Assess for pallor and cyanosis during activity. • Assess oxygen saturation level; apply and maintain supplemental oxygen as needed and ordered. Gastrointestinal System Decreased peristalsis • Encourage high-fiber foods, high fluid intake, activity, and appropriate use of laxatives and stool softeners. Dryness of the mouth • Perform mouth care every 8 hours or more often as needed. Impaired sense of taste • Encourage balanced, nutritional meals of foods the patient likes to eat. Endocrine System Impaired blood sugar regulation • Encourage balanced, nutritional meals and regular exercise. • Assess finger stick blood sugar as ordered and administer ordered antidiabetic medications. Reproductive System Decreased estrogen production in females • Educate about lubrication products and locally applied estrogen creams to decrease vaginal dryness. Decreased circulation to genitalia in males • Encourage discussion of erectile dysfunction if it is a problem. • Discuss blood sugar and blood pressure control, which can help decrease development of erectile dysfunction. Genitourinary System Impaired emptying of bladder • Scan the bladder to detect urinary retention. • Assess for signs and symptoms of urinary tract infection (UTI): burning during urination, urgency, frequency, cloudy urine, and a foul odor to urine. • Encourage fluid intake of liquids the patient likes to drink. Decreased renal function • Assess intake and output every 8 hours; observe for decreasing urine production, making certain that kidneys are producing the minimum of 30 mL/hr. Assess laboratory results for renal function: blood urea nitrogen (BUN), creatinine, glomerular filtration rate (GFR). • Assess intake and output every 8 hours; observe for decreasing urine production, making certain that kidneys are producing the minimum of 30 mL/hr. Incontinence • Implement bladder training when appropriate; assess for wet bed every hour; change wet linens as soon as detected; keep perineum and buttocks clean and dry. • If using adult waterproof underwear, avoid calling them diapers. • Treat incontinent patients with respect. Musculoskeletal System Osteoporosis • Encourage weight-bearing exercise. • Encourage increased calcium intake in foods and supplements. • Encourage compliance with other medications for bone strength. • Encourage the installation and use of handrails in tubs and around toilets in the patient's home. • Encourage the use of commercial "emergency help signal devices" that can be worn around the neck and activated when the patient falls or becomes seriously ill. Contractures • Perform range-of-motion exercises at least once or twice per day if a patient is unable to ambulate. • Encourage neck, arm, and leg exercises that can be performed while sitting in a chair. • Use hand rolls to prevent contractures of hands. • Maintain proper body alignment both in bed and when sitting in a chair. • Encourage the patient to perform as much self-care as able. Integumentary System Skin easily damaged • Encourage protection of skin, such as wearing only closed-toed shoes. • Assess and cover all skin tears or open areas. • Apply creams and lotions to prevent cracking of skin. Increased capillary fragility • Assess all injuries, even seemingly minor ones. • Ensure that bleeding is controlled and stopped. • Be careful to avoid bumping or scraping the patient's arms and legs on bed rails, bed frames, wheelchairs, or chair legs. • Be gentle when handling the patient; when applying tape to the skin, use the least amount that will accomplish your goal. • Report bleeding gums. Decreased circulation to skin and underlying tissue • Turn immobile patients every 2 hours, and encourage frequent position changes in patients who can turn themselves. • Place pillows between knees and ankles when in side-lying positions. • Keep sheets as wrinkle-free as possible. • Avoid allowing the patient to lay in a wet bed. • Change linens frequently. • Position heels so they do not constantly rest on the bed. • Use sheepskin elbow and heel protectors as needed. • Provide skin care several times per day if the patient is bedridden. • Assess pressure points for erythema at least every 4 hours, sometimes as often as every 2 hours. • Encourage adequate fluids and nutrition; provide protein supplements if needed. It is difficult for family members to watch a loved one who has developed multiple medical problems "slip away" from them, particularly when one of the medical concerns is Alzheimer's disease or another form of dementia. Family members often describe this process as taking care of someone they feel like they do not know because the cognitive changes seen in dementia seem to rob the patient of distinct personality features. While the nursing care for patients with dementia often focuses on maintenance of safety and assistance with activities of daily living, the care given to the caregiver is just as important and focuses on preventing burnout. Box 32-1 lists signs of caregiver burnout. Real-World Connection Alzheimer's Disease A 75-year-old woman was caring for her elderly husband who had multiple illnesses as well as Alzheimer's disease. She was devoted to him and was his sole caregiver. Eventually, hospice was called in to provide additional in-home care. His wife struggled with watching his decline and accepting help with his care. She felt as though she was losing her husband and best friend as he became more and more withdrawn. The hospice nurse answered her questions honestly and allowed her to verbalize her sadness regarding the fact that he would not get better. As her husband's physical and neurological function continued to decline, it was suggested that he be moved to a skilled nursing facility. This was extremely difficult for his wife to allow because she kept wondering if she could do more to be able to keep him home. Once again, the hospice nurse helped her see the reality of the situation. Using criteria recommended by the Alzheimer's Association (Box 32-1), the nurse assessed the wife's stress level and risk for burnout. The nurse also helped her understand that she was becoming overwhelmed, losing weight and sleep, and unable to keep her husband safe in the home setting. The nurse reassured the wife that he would be safe and attended to 24 hours a day, 7 days a week, at the skilled nursing facility. Three weeks after his admission to the facility, he passed away peacefully, and his wife was grateful for the care he was given prior to his death. Although her husband did not survive, she was at peace with her decision and valued those last days with him because she could completely focus on being with him rather than trying to complete the innumerable tasks related to his care. When you care for patients and family members in similar situations, it is important for you to help the family realize that it is not a sign of failure, but a sign of strength, to tap into the help available for both them and their loved one. Box 32-1 Signs of Caregiver Burnout When you are caring for a patient who has family members or friends involved in his or her care, it is important to pay attention for the signs of caregiver burnout. Even though caregivers are not necessarily sick, giving care to a loved one can be a very stressful experience. Ask these questions when assessing whether or not a caregiver is experiencing burnout: • Does the caregiver feel that he or she must be the exclusive care provider? • Does the caregiver feel that he or she is withdrawing from other friends, family, or activities because of the care he or she must provide for the loved one? • Does the caregiver worry about the safety of the loved one? • Is the caregiver anxious about finances and making health-care decisions for his or her loved one? • Is the caregiver denying the impact of the disease and its effects on the family? • Is the caregiver experiencing grief or sadness that the relationship with the loved one is deteriorating? • Does the caregiver get frustrated or angry when the loved one does not listen? • Is the caregiver experiencing personal health problems in addition to caring for the loved one?

physical changes

Changes in Sensory Functioning Encompassing vision, hearing, taste, smell, and touch, the senses are also affected by slowing of the transmissions in the nervous system. Common visual disturbances in older adults include cataracts and glaucoma. Cataracts occur when the lens of the eye becomes cloudy, or opaque, causing visual blurring. Glaucoma is an eye disease characterized by increased intraocular pressure, which affects the optic nerve and can lead to blindness. Age-related macular degeneration is the destruction of the area in the retina where the optic nerve attaches, leading to the loss of central vision. In addition, many older adults complain of dry eyes due to less tearing and changes in visual acuity related to complications of untreated hypertension and diabetes. As with neurological changes, decreases in the sensory abilities predispose patients to injuries. Presbycusis, or the normal decrease in hearing that accompanies the aging process, can increase the risk for injury if people cannot hear alarms and sirens. They often are unable to hear even the telephone unless they are present in the same room as the phone. When caring for a patient with decreased hearing, avoid shouting in an attempt to make them hear. It usually works best to lower the pitch of your voice, speak to the ear in which the patient hears the best, and slightly raise the volume of your voice. Another tactic that sometimes helps is to be on the same physical level as the patient and speak slowly, allowing him or her to read your lips. Inner ear disturbances can affect equilibrium, increasing the chance of falls. The number of olfactory nerves decreases, diminishing the sensation of smell, making it more difficult to detect things such as food spoilage or gas leaks. Touch sensation can be decreased as peripheral blood flow decreases. The taste buds become less sensitive, requiring stronger flavors to stimulate the patient's sense of taste. This is why many older adults tend to eat more sweet desserts than when younger, because they can better taste sweets than other tastes. When patients do not taste and enjoy foods, they are less likely to consume the needed amount of nutrients to maintain their appropriate body weight. So, if an older patient wants to eat his or her dessert first at mealtime, this should be allowed. Avoid treating them as children, telling them they cannot have their dessert until after they have eaten the other things on their plate. Table 32-2 provides information regarding sensory deficits and the recommended nursing actions for these concerns. Changes in Cardiovascular Functioning As patients age, the heart muscle loses elasticity, the blood vessels narrow as arteries collect fatty deposits, and peripheral pulses are less palpable. Circulation is decreased, resulting in patient complaints of feeling cold, especially at bath time. These patients require a warmer room and warmer clothes than do younger people. These circulatory changes may occur without the patient's awareness, which puts the person at high risk for developing conditions such as coronary artery disease, hypertension, high cholesterol levels, myocardial infarction (also known as heart attack), or peripheral vascular disease. It is estimated that approximately two-thirds of individuals older than 65 years have coronary artery disease. Table 32-2 provides information regarding the cardiovascular changes that occur with aging and the recommended nursing actions for these concerns. Changes in Respiratory Functioning In an aging patient, you would expect lung elasticity to be decreased. As with many body systems, the flexibility of the normally elastic lung tissue is reduced over time. The alveoli do not expand fully, which increases the risk for pneumonia, bronchitis, and complications of underlying chronic pulmonary disease. Older adults are also more vulnerable to infections, particularly respiratory infection due to decreased immune function. Therefore, be sure to educate patients about ways in which to protect themselves from easily contracted infections. Table 32-2 provides information about ways to help patients protect themselves from respiratory illnesses. Changes in Gastrointestinal Functioning As peristalsis slows in the older adult, the cycle of food digestion slows, which can lead to poor appetite and decreased food intake. This may then result in malnutrition, weight loss, and an overall decrease in immune function. It is very important that you investigate the cause of a loss of more than a few pounds or kilograms in patients who are not trying to lose weight. Constipation may result from numerous factors. Many medications list constipation as a side effect. As patients grow older, their lack of activity may slow down the entire gastrointestinal functioning, including evacuation. Aging can affect peristalsis, increasing the amount of time that feces remains in the large intestine, causing more water to be absorbed, leaving the stool dry and hard. Some older adults become very focused on the frequency of their bowel movements and become distressed easily if constipation occurs. Administer ordered medications such as stool softeners and laxatives to help prevent this problem. Xerostomia is the medical term for an excessively dry mouth. This is a common complaint of older adults, as many medications can dry normal secretions. The cells in the salivary glands, just as in the rest of the body, diminish in size and number, which compounds this problem. Table 32-2 provides information regarding deficits of gastrointestinal functioning and the recommended nursing actions for these concerns.

classificationlassfication of age groups ofC

Classifications of Age Groups For purposes of understanding how nurses care for the aging population, it is helpful to classify the different age groups of older adults. Each stage has its own nuances, in terms of physiological and psychosocial changes that take place. Individuals will also experience changes related to developmental, sociocultural, and spiritual issues that occur within these stages of older adulthood. These will be described in more detail later in this chapter. It is important to realize that, in today's world, people live longer than ever before, particularly in Western society. This is due in part to changes in the health-care system that make it better equipped to manage chronic disease conditions. With that in mind, it is not unusual that people do not see themselves as old because they continue to enjoy many of the same activities they enjoyed as a younger person, even though they are now older. Young-Old The "young-old" are individuals aged 65 to 75 years. They also may be referred to as the young elderly. They have just started experiencing more of the physiological changes that are brought on by the aging process, although they may have experienced a somewhat gradual decline in physical health in the preceding decades. Common conditions seen in young-old individuals include elevations in blood pressure, higher cholesterol levels, and the onset of type 2 diabetes. Particularly in Western cultures, these conditions are prevalent due to sedentary lifestyles and the consumption of diets that are low in fiber and high in fat and animal proteins. Although the young-old may experience some changes in health, it is not uncommon to find them still working in the public or private sector, or volunteering, while maintaining a social network of friends. It is within the next stage, middle-old, where physical and psychosocial changes begin to become more apparent. Middle-Old The "middle-old" are individuals aged 75 to 85 years. These are people who often have retired from working and who are experiencing the losses of spouses, family members, and friends to death. Physical changes are more apparent and often require that people refrain from doing things that formerly brought them pleasure, such as gardening, hobbies, and traveling. Although it is important to assess for depression in any patient, it is of particular importance to recognize that these individuals may be at higher risk for the development of a psychosocial disorder because of the implications of physical and social changes that affect their lives at this time. Old-Old The "old-old" are those who are 85 years and older. Often their health has significantly declined, leaving these people with the need for regular, and sometimes around-the-clock, assistance. According to the Congressional Budget Office, more than two-thirds of elderly persons 85 years and older report functional limitations and require assistance with activities of daily living. The manner in which these needs are met is often determined by the person's culture. In Eastern cultures, elderly citizens are valued, and most often the old-old reside with family members. In Western cultures, many times younger family members are working as well as raising their own children, so it is more common for the old-old to live in long-term care or assisted living facilities. In Western civilization, when middle-aged individuals are caring for frail, elderly relatives and are also raising their dependent children, it is commonly referred to as "sandwiching," meaning that the middle-aged generation is sandwiched between raising a family and caring for aging relatives. The U.S. Census Bureau projects that the old-old will be the fastest growing age group of the elderly populations into the next century. Elite Old The "elite old," also called centenarians, are 100 years of age or older. According to the 2010 U.S. Census, there are 53,364 Americans older than 100 years of age. This is up from 50,459 in 2000. Of those older than age 100 years, 80% are female. Again, this is testimony to better medical management of chronic conditions.

physical assessment

Documentation Documentation for residents in LTC facilities is less frequent and detailed than that done in acute care. Routinely, the nurse makes one entry in each resident's record once per week or according to the facility's policy. Additional entries must be made for any change in condition, for signs or symptoms indicating possible problems, and when an accident occurs or injury is sustained. It will be your responsibility to know your employer's facility documentation policy. In addition, you will document medications according to the facility's policy. Physical Assessment of the Older Adult Assessment Considerations for Hospitalized Elderly Adults Although the physical assessment that you learned to do in Chapter 21 is identical to what you will perform for older adult patients, there still are elements that you need to focus on more intently to make this process as comfortable as possible. Box 32-2 provides tips for when you are performing a physical assessment on a hospitalized older adult. In addition to the physical assessment, it is important to assess the patient for mental status and depression. A Mini-Mental State Exam (MMSE) is often used to ask patients simple questions to determine their cognitive abilities. This may not be within the LPN/LVN's role, but you should be aware of this type of assessment. Assessment Considerations for Residents in Long-Term Care When you care for acutely ill patients in the hospital setting, you perform a head-to-toe physical assessment at the beginning of each shift on each patient, and additionally as the patient's condition warrants further assessment. This is one of the biggest differences you will find in an LTC facility. A complete head-to-toe assessment is generally performed once a month unless the resident exhibits signs or symptoms of illness or suffers an injury, in which case assessment is performed based on the resident's condition and the frequency cited in the facility's policy. However, the assessments that are performed once a month include additional data beyond the traditional head-to-toe physical assessment. Some of the additional assessments that are made include: • General appearance: characteristics such as emaciation, dry hair, or drooping on one side of the face • Adaptive equipment: hearing aids, eyeglasses, dentures, and any prosthesis such as an eye or a limb • Ability to communicate: includes verbal communication or nonverbal communication, with the method that is used if the resident is unable to speak • Level of cognition: including degree of dementia if present • General eating habits: how well the resident generally eats at mealtimes; dentition and ability to chew; type of diet, snacks, and supplements; level of hydration; swallowing or aspiration problems; required use of thickening agent in liquids • Special nutritional assistance: nasogastric or percutaneous endoscopic gastrostomy feeding tubes, type and amount of formula, frequency of instillation, tolerance of feedings, special body positioning required for feeding, frequency of assessment of tube placement • Bowel and bladder elimination status and habits: continent or incontinent, presence of Foley catheter or ostomy, problems with diarrhea or constipation • Ambulatory status: bedbound; whether one- or two-person assist or total assist is required for transfers; ambulates independently; able only to sit in a chair or lie in bed; requires use of cane walker, rolling walker, quad cane, single-prong cane, or gait belt to ambulate; or transferred with a wheelchair or geri-chair • Sleep habits: how well the resident sleeps at night, whether or not the resident wanders, whether the resident is routinely awakened by pain • Medical equipment: such as oxygen, suction machine, splint, cast, feeding pump • Activities: include frequency of participation in activities, type of activities attended, as well as frequency of visitors Box 32-2 Tips for Performing Physical Assessment on Hospitalized Older Adults When you obtain a health history, be certain to consider the patient holistically. Beyond the physical presentation of the patient, there are often emotional, psychological, spiritual, or sociocultural needs that are pressing to an older adult. Before you perform the physical examination, consider which accommodations might make this process easier for the patient. These may include: • Extra attention to safety: Because elderly patients may not be steady, consider how to make the physical assessment a safer experience. This may include assisting with transfers, helping the patient to move in the bed, and assisting the patient with disrobing and dressing as necessary. • Sessions: Older adults may not be able to tolerate an entire physical assessment performed at once due to excessive fatigue. Plan your assessment to avoid tiring the patient. You may need to do part of the assessment, then allow the patient to rest a bit before you complete it. • Concentration and attention span: Older adults may have difficulty answering a large number of questions about health history information, especially all at once. If possible, have a knowledgeable family member available to help answer health history questions with the older adult. • Extra time: Avoid rushing the older adult during a physical assessment. Plan to spend extra time performing the assessment and to allow for questions to be answered. Patients will be more comfortable if they do not feel rushed. Knowledge Connection Discuss at least three safety issues about which you must be concerned when providing nursing care in a long-term facility. Explain why we refer to the long-term care population as "residents" rather than "patients." The Problem of Polypharmacy in Elders When a patient is taking multiple medications, a potential concern exists for polypharmacy complications. The term polypharmacy refers to the ingestion of many medications. It is common for the older adult to have more than one physician as he or she has developed various conditions over time. For example, the individual may have a primary family doctor, a cardiologist for heart problems, a pulmonary specialist for respiratory disease, and an internal medicine physician for diabetes. All of these physicians may prescribe medications to treat separate conditions. Even though all of these medications are prescribed, their cumulative effects may cause adverse reactions or may result in drug-drug interactions because they are being taken together. Ideally, each physician should inquire regarding other medications the patient is already taking, but this does not always happen. Even when a physician does ask a patient about medications he or she is currently taking, the physician may still order a same-type drug, but by a different name, thus putting the patient in jeopardy of overdose or drug toxicity. Patients are often unaware of the reason for each of the different medications. They also may lack knowledge about the function of each medication and the possible interactions between drugs. Too often, health-care workers hear patients say, "I take a little white pill, and a blue pill, and a pink pill," but they cannot identify the names of the medications or the reasons for taking them. Safety: It is paramount that you teach patients and family members to maintain a complete list of all medications and the dosages being taken. This list should accompany the patient any time he or she goes to the physician's office or to the hospital. Patient Teaching Connection Teaching Patients About Medications for Multiple Conditions When working with a patient who takes multiple medications, teach the patient the details of the drug regimen, including: • Reasons for taking each medication • Dosage for each medication; for example, one pill or two pills, or the number of milligrams • How often each medication is taken; for example, twice or three times a day • Whether the medication should be taken on an empty stomach or with food • Safety precautions associated with each medication • How to tell if the medication is effective • Potential side effects of each medication • Interacting substances; for example, if the medication would interact with alcoholic beverages Also teach the patient how to store medications for maximum safety and how to devise an administration system, because some patients do very well if they have a system for medication administration. Suggestions include a check-off calendar for each dose of each medication and a storage device that separates each dose for each day of the week.

promoting wellness

Healthy People 2020 Healthy People provides science-based health goals and objectives to improve national health and prevent disease. The goals and objectives are revised every 10 years. Through the office of Disease Prevention and Health Promotions, part of the Department of Health and Human Services, Healthy People 2020 continues to work toward improving the prevention of disease and promoting health in the United States. The overarching goals of this program are to: • Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death • Achieve health equity, eliminate disparities, and improve the health of all groups • Create social and physical environments that promote good health for all • Promote quality of life, healthy development, and healthy behaviors across all life stages The current 10-year promotion, Healthy People 2020, contains about 1200 objectives in 42 Topic Areas in a framework designed to help improve the health of all people in the United States. For each Topic Area, indicators and objectives exist to measure improvement in that area. . Health Literacy When health-care professionals explain to patients how to prepare for a test, how to take medications, or any number of other instructions, they assume the patient understands, especially if the patient asks no questions. The truth is that sometimes patients do not actually understand, resulting in illnesses or complications that could have prevented. In an effort to address this communication gap, the concept of health literacy was developed. Health literacy refers to the ability of individuals to understand basic health information and to use that information to make good decisions about their health. Assessing health literacy is so important that it has been referred to as the "newest vital sign." Healthy People 2020 Topic Areas The 42 Topic Areas included in the Healthy People 2020 initiative are: • Access to quality health services • Adolescent health • Arthritis, osteoporosis, and chronic back conditions • Blood disorders and blood safety • Cancer • Chronic kidney disease • Dementias, including Alzheimer's disease • Diabetes • Disability and health • Early and middle childhood • Educational and community-based programs • Environmental health • Family planning • Food safety • Genomics • Global health • Health-care-associated infections • Health communications and health information technology • Health-related quality of life and well-being • Hearing and other sensory or communication disorders • Heart disease and stroke • Human immunodeficiency virus (HIV) • Immunization and infectious diseases • Injury and violence prevention • Lesbian, gay, bisexual, and transgender health • Maternal, infant, and child health • Medical product safety • Mental health and mental disorders • Nutrition and weight status • Occupational health • Older adults • Oral health • Physical activity • Preparedness • Public health infrastructure • Respiratory diseases • Sexually transmitted diseases • Sleep health • Social determinants of health • Substance abuse • Tobacco use • Vision The idea behind the concept is that health-care professionals should assess patients for their ability to comprehend health-care information and to use it to make decisions. Several tools are available to measure health literacy, but one very popular tool uses an ice cream label to assess the patient's ability to use numbers, make calculations, identify potentially harmful ingredients, and make informed decisions before taking action. The patient is given a specific ice cream label to refer to during the assessment. The health-care professional then asks the patient six questions and scores the answers according to a score sheet. The questions are always asked orally. Examples of the questions include: • If you ate the entire container of ice cream, how many calories will you eat? • If you usually eat 2500 calories in a day, what percentage of your daily calories will you be eating if you eat one serving? • Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves, and bee stings. Is it safe for you to eat this ice cream? You may not be surprised to learn that only 12% of the population has a proficient health literacy score according to the National Assessment of Adult Literacy. Research has shown that people who have low health literacy are at higher risk for poor health regardless of other factors such as educational level and age. It is extremely important for health-care professionals to ensure that patients understand the information they receive.

illness

In spite of efforts to promote wellness and decrease risky behaviors, people do become ill. Illness is not always due to the person's lack of effort to remain healthy. Some people do nothing to achieve a healthy lifestyle, engage in a number of risky behaviors, and are diagnosed with an illness, as expected. At other times, people work very hard at being healthy and are shocked when they develop a sudden severe illness. Although cause and effect regarding lifestyle choices and illness have been proven to exist, sometimes illness occurs without previous risk factors. Therefore, it is important that you do not "blame the victim" when you care for patients who have been diagnosed with an illness or disease. Just as it is difficult to know what caused an illness or why it happened to a particular person, it also is difficult to predict each person's response to illness. Some people seem to take even devastating diagnoses in stride, while others seem to panic over a diagnosis of a relatively minor, easily treated disorder. Types of Illness To some people, illness is defined as "not being able to do what I want to do." To others, illness could be defined as "any pain or discomfort because it means my body is not functioning normally." It is difficult to determine a single definition of illness because several types of illness exist, and people perceive illness differently. An acute illness strikes suddenly and lasts for a limited time. An example of an acute illness would be food poisoning: you become very ill a few hours after ingesting contaminated food. You experience severe symptoms of nausea, vomiting, and diarrhea for 24 to 48 hours. Once your body rids itself of the offensive contaminants, you begin to feel better. Acute illness also can occur in situations in which hospitalization is required. For example, a patient is admitted with acute appendicitis and has an emergency appendectomy, or removal of the appendix. After surgery, the incision gradually heals and the patient eventually returns to normal activities. A chronic illness is one that lasts for 6 months or longer and is characterized by intensifying or improving symptoms. Chronic illness may require treatment and medications or limitation of a person's activities. An example of a chronic illness would be chronic obstructive pulmonary disease (COPD). People with COPD often are dependent on supplemental oxygen and have a low energy reserve because of the effort required to breathe, thus limiting activities in which the person is able to participate. Chronic illness is characterized by periods of either minimal symptoms or a complete absence of symptoms, called remissions, and periods of worsening symptoms, called exacerbations. Rheumatoid arthritis is an example of a chronic illness with periods of remission when joint pain lessens and mobility improves, and exacerbations when the opposite occurs. Phases of Illness Before a person develops symptoms of a specific illness, he or she may simply "not feel good," with generalized body aches and fatigue. This is referred to as the prodromal phase of illness. As observable symptoms develop—for example, a sore throat and congestion, or a rash with a fever—the person enters the symptomatic phase. At this point, he or she makes a choice to either wait and see if the symptoms resolve, treat himself or herself with over-the-counter products or home remedies, or seek advice from friends and relatives. Next comes the seeking help phase. The majority of people in our society seek help from a medical professional, such as a physician, physician assistant, or nurse practitioner. However, in some cultures, people may seek help from healers rather than physicians. Some seek out herbalists or other alternative practitioners Once a person has sought help, he or she must decide to follow the advice or recommended treatment, or to seek help elsewhere. In this dependency phase, a person relies on others for help in diagnosis and treatment. In many cases, the individual not only must depend on others for medical care, but he or she also may be forced to rely on others to perform his or her work or family duties. Different people react in different ways to the dependent role. As the nurse, you are often the one whom patients must depend on during this phase of illness. Many patients adapt to this dependent role without difficulty, realizing it is a short-term situation; other patients react by becoming angry, fearful, or overly dependent; and still others may become manipulative. The final phase is the recovery phase, when the person is slowly able to resume independence and regain his or her health. It should be noted that people with a chronic illness often remain in the dependency phase because complete recovery is not possible. Knowledge Connection Contrast acute and chronic illness. Contrast exacerbation and remission. List the five phases of illness. Risk Factors for Illness Researchers have identified risk factors for some illnesses. These are physiological, psychological, or genetic elements that contribute to the development of an illness or disease. Another type of risk factor is environmental elements, such as exposure to a chemical hazard that could lead to illness. Some risk factors can be modified or changed by alterations in lifestyle and nutrition. Other risk factors are nonmodifiable, such as heredity, age, and gender. People who have risk factors for illnesses such as diabetes, heart disease, stroke, and cancer may be able to decrease their risk of developing the illness by modifying their diet and exercise routine, as well as managing their blood pressure and blood sugar. An increasingly common modifiable risk factor for many illnesses is overwhelming stress and a lifestyle that lacks balance among work, play, and rest. Cancer can have some familial tendencies (be passed down in families), which is a nonmodifiable risk factor. The American Cancer Society has identified seven warning signs of cancer;

long term acute care hospital

LTACH focuses on patients with serious medical problems that require intense, special treatment for a long period of time, usually about 20 to 30 days. These patients often transfer from intensive care units in traditional hospitals. It would not be unusual for a patient in an LTACH to need ventilator or other life support medical assistance. The health-care team in an LTACH is composed of members similar to those in the acute care hospital. A physician visit is required daily. An example of the effective use of this level of care is a situation in which a patient is in intensive care on a ventilator after lung surgery and develops an infection in the chest cavity. The patient is stable on the ventilator and will have to remain on it until the infection is completely cleared, which could be up to a month. It would be extremely expensive for the patient to remain in an acute care hospital during that time. The patient is transferred to an LTACH for continued treatment of the lung infection and ventilator support.

longterm

Long-Long-Term Care Nursing While the aging process has the advantages of wisdom, more life experiences, and new and different opportunities, it also sometimes involves the loss of ability to live independently because of health problems, whether physical or mental. Many older adults may find it necessary to live in assisted living facilities or long-term care (LTC) facilities, more commonly known as nursing homes. You probably will have the opportunity to perform some of your clinical experiences in an LTC facility, and you will find that providing nursing care for these individuals is vastly different from the care you provide in an acute care setting. One difference is how you refer to those for whom you provide care. Patient or Resident? You typically refer to the population within acute care facilities as patients or clients. Those individuals are in the facility temporarily because they require some type of diagnostics or treatment for health problems. Most individuals for whom you will provide care in LTC facilities are not there temporarily; they reside, or live, there. The facility is their actual home, their residence, and their place of refuge from society, although many of them would prefer to live somewhere else if they could. It is considered more appropriate to refer to these individuals as residents rather than patients. Residents' Needs Using the term resident may help you to maintain the focus of your role in providing nursing care. Even though an acute care patient and an LTC resident may have some of the same needs, you will have additional opportunities to meet more needs in the LTC setting. In acute care, you prioritize needs according to Maslow's hierarchy of needs, but it is performed within a much smaller time frame than in an LTC facility and may not require you to address needs from every level. When you care for patients in an LTC facility, your primary focus will be to provide ongoing life services for the residents—those things we all need and desire, which address all levels of Maslow's hierarchy of needs: • Oxygen and fresh air, water and nutrition, healthy elimination • Rest and sleep, comfort and pain relief • Optimal health • Safety and security • Spiritual edification • Freedom from anxiety and fear • Love and affection, acceptance by others • Self-respect and being respected • Self-esteem and self-confidence • Productivity and self-worth • Simple enjoyment and fulfillment in daily life Helping to Meet These Needs You will have ample chances to meet more of these needs than you will probably ever realize. When you enter an LTC facility, you have a unique opportunity to impact the lives of the residents and a chance to make their days brighter and more fulfilling. You have the opportunity to bring compassion, respect, comfort, and affection while you provide nursing care. One of the benefits for you is the opportunity to learn from a wealth of wisdom that the residents have to share. Many of them will have lived and experienced decades of life beyond that of the typical student. We all can learn from the older and wiser generations if we are willing. Encourage residents to reminisce and tell about events they have experienced. Listen attentively as you get to know the resident better, and you may gain knowledge or develop a better appreciation for the past. You also might enjoy it. The LTC setting is different from acute care in a variety of ways: the contents of rooms, personal attire, personal care, nutrition and hydration, elimination and toileting, immobility and activity, medications, assessment, and documentation. Resident Rooms Because LTC residents are living in the facility rather than spending a day or two there, it is important to remember that their rooms are their personal residences. It is even more important that you knock before entering their room, just like you do before entering someone's house. Residents may bring personal items, sometimes even pieces of furniture, to personalize their residence. Encourage residents to hang photographs and the artwork of grandchildren or other significant young ones. Use personal blankets, pillows, and afghans when available. Provide whatever assistance is required to keep the room, floor, and bathroom clean, but allow the resident to arrange his or her possessions as desired. It may look cluttered to you, but it may be just the way he or she wants it. Offer to help organize or straighten articles if the resident requires or desires assistance. If the resident is immobile or has severe dementia, it will be your responsibility to maintain the room's appearance and organization so that safety is not sacrificed. Personal Attire The resident wears his or her own clothing and shoes, unless the resident's condition is such that he or she requires continual medical and nursing intervention that is hindered by wearing personal clothing. Assist the resident as needed to get dressed each morning. If the resident is incontinent, change his or her clothing immediately. Families of residents may or may not prefer to do the resident's personal laundry. Some residents will require that the LTC facility employees launder their clothing. If this is the case, it is important for the resident's name to be written with a permanent marker on the label or inside the neck of the garment. Even socks and underwear must be marked to prevent misplacing articles of clothing in another resident's laundry. Safety: Make certain that residents' shoes have nonskid soles to decrease the risk of falls. If the soles are somewhat slick, it is helpful to apply several strips of adhesive tape across the soles of the shoes. The cloth side of the tape helps prevent slipping on a tile floor. Personal Care Some residents may be able to perform their daily hygiene without assistance, but many will need assistance. For these residents, you will provide personal care, but on a slightly different schedule than in acute care. For example, most residents will not take a complete bath every day. Aging skin becomes drier and more fragile, so many residents will prefer to take a complete tub bath or shower only two to three times per week. On nonbath days you will wash the resident's face, hands, feet, and perineal area daily and as needed. Most facilities have shower rooms or tub rooms, with several tubs and shower stalls, which must be shared by all the residents. Safety: You will need to disinfect shower chairs, tubs, and mechanical lifts after each use. This is paramount to prevent cross-contamination. Without stringent disinfection between residents, it is possible to spread diseases caused by highly contagious organisms such as Clostridium difficile (C. diff.). This bacterium causes severe diarrhea that has the potential to be fatal in elderly and immune-suppressed individuals, and it can spread quickly throughout a facility. Provide privacy for the residents by pulling the curtains between the bathing stations and ensure that the doors are kept closed while bathing facilities are in use. Safety: Immediately mop up all water that is splashed or dripped onto the floor to prevent falls. Whirlpool tubs are commonly used for bathing, providing the additional benefit of stimulating the circulation and débriding any wounds the resident may have. Safety is a real issue when bathing residents. It would be easy for residents with impaired mobility or dementia to drown in a whirlpool tub because of the depth of water. Safety: Never leave a resident unattended while he or she is bathing! Environmental temperature must be kept warm enough that the resident will not become chilled. Some residents are unable to stand or access the bathtub or whirlpool tub without the use of a mechanical lift. You learned about safe usage of this equipment in Chapter 16. Safety: Remember to obtain an adequate number of coworkers to provide safe handling while transferring residents via a mechanical lift. Provide hair care for residents on a daily basis, and wash their hair at least once a week or more often if needed. Many LTC facilities have beauty and barber shops, allowing residents to schedule appointments with professional stylists. If the facility does not have these types of services available or if residents do not have someone who assists them in these matters, you will assist with styling their hair. It will help you to meet this need more easily if you think how you would feel if you were unable to perform these activities and no one else cared enough to assist you. Everyone wants to look their best to receive friends and loved ones when they come to visit; appearance is part of self-esteem. Male residents may require assistance with shaving, some daily and others only two to three times per week. Safety: If a resident has supplemental oxygen being delivered, turn it off for at least 10 minutes before shaving with an electric razor to allow the higher oxygen levels in the room air to dissipate. If the resident cannot tolerate the removal of oxygen for that length of time, you will use a safety razor. Safety: Before using a safety razor, assess whether the resident is taking anticoagulants such as warfarin (Coumadin), which would put the resident at risk for excessive bleeding in the event you accidentally nick his skin. Follow the facility's policy regarding the use of electric and safety razors. You will perform nail care more frequently in an LTC facility than in an acute care setting. Follow the facility's policy carefully regarding who may cut or trim nails, especially those of a resident with diabetes or peripheral vascular disease (refer to Chapter 15). Nutrition and Hydration Although you provide meals, snacks, and fluids to patients in acute care, the responsibility is more extensive in an LTC facility. It is your responsibility to make certain that each resident maintains adequate dietary intake by: • Ensuring that dentures are inserted for meals • Assessing whether the food needs to be finely chopped or pureed • Feeding or assisting the resident to eat, as needed • Monitoring and recording the percentage eaten at each meal • Ensuring that adequate fluids are ingested, usually a minimum of 1500 mL/day • Providing supplemental protein and carbohydrate drinks as needed • Monitoring for weight loss on a weekly or monthly basis Most LTC facilities have a policy addressing interventions to implement when a resident eats 50% or less of the food served for a meal. The most common intervention is to provide a supplemental nutrition drink, such as Ensure, between meals. Accrediting agencies look for documentation that this has been done. It is important that all residents who are able be taken to the dining room for each meal. Meals are a social event for most people, and this gathering allows residents to see, greet, and converse with their neighbors. Figure 32-6 shows residents socializing during a meal. For residents who are immobile, it is even more important to transfer them to the dining room for all three meals each day so that they have more opportunity to interact with others. You may transfer residents via a wheelchair or a special chair called a geri-chair. A geri-chair is a recliner with side arms, a lap belt, and wheels so that it can be navigated through the hallways. It is used for residents who are unable to sit unassisted. Figure 32-6 These residents are socializing during a meal. (PunchStock.) The dining room in most facilities contains multiple tables with assigned seats for each resident. This allows the staff to deliver special diets to the correct residents. Safety: Always check the resident's meal card and diet before delivering the tray to the resident. When a resident is unable to feed himself or herself, you must assist him or her. It is important to sit in a chair next to the resident, rather than to stand. This puts you at eye level with the resident, which improves communication and allows the resident to see your face. Some residents are unable to look upward to see someone standing, towering above them. It is important to make mealtimes as pleasant as possible. Converse with the residents and include them in conversations whether or not they are able to verbalize. Try to make the mealtime a happy and social time, as it can be in the home with one's family. Elimination and Toileting Not all residents in an LTC facility are incontinent of bowel and bladder, but many will be. Check incontinent residents every 1 to 2 hours for the need to be changed. Avoid allowing a resident to lie or sit in wet or dirty clothes or linens. Change them as needed, and provide scrupulous perineal and skin care to prevent skin breakdown. Some residents may require barrier ointments to aid in protecting the skin from urine and feces. Avoid using the term diaper for incontinence briefs. Treat the resident with respect when you are changing the brief and washing the perineum after incontinence. It is important to monitor and record whether or not each resident has a bowel movement on every shift. Residents with impaired mobility are particularly at risk for constipation. Most facilities have a policy requiring that each resident be provided with a stool softener or laxative if the resident does not have a bowel movement at least every 3 days. Careless tracking of daily bowel movements can result in fecal impaction, which is a very uncomfortable condition for the resident. (See Chapter 30 for more information about fecal impaction.) Immobility Residents can develop impaired mobility if you do not take action to prevent it. Encourage residents to get out of their rooms and to ambulate as much as possible. Encourage participation in exercise sessions and outdoor walks. Encourage those with gardening interests to help tend to the flower gardens if they are physically able. Lead groups of residents in chair exercises, which can help prevent loss of strength and preserve joint mobility. Frequently reposition bedfast residents and those who are restricted to sitting in a chair and unable to walk. The longest any resident should remain in any one position is 2 hours. Repositioning, assessing pressure points for erythema, and applying lotion as needed are paramount to preventing pressure ulcers. Encourage residents, if they are able to do so, to sit in a chair for meals and to attend social events. Provide passive and active range-of-motion exercises for bedfast residents to increase circulation and to prevent atrophy of muscles and contracture formation. Exercises should be performed at least once or twice per shift during daytime hours. Also encourage the resident to do as much as he or she is able to do with regard to activities of daily living (ADLs). For example, if a resident is only able to wash his or her face and hands and brush his or her teeth and hair, encourage the resident to do so. Avoid doing it all yourself in an effort to "get done" because you are busy. Participation in self-care helps to increase activity but also fosters confidence, independence, and self-esteem. Activity and Entertainment Most LTC facilities schedule regular activities for the residents to participate in as they are able. Some examples include: • Craft-making sessions • Manicure sessions • Domino tournaments • Group singing and karaoke • Movie time • Current event discussion groups • Daily reading aloud of the newspaper or Bible • Paint-by-number pictures, watercolors, and finger painting • Bingo • Ice cream socials • Book time, where a novel is read aloud each session until completed Some LTC facilities may include music sessions in which residents are provided with instruments to play in accompaniment to someone playing the piano. Instruments may include triangles, cymbals, sticks, bells, tambourines, small hand drums, kazoos, or harmonicas. Encourage residents to participate in as many of these activities as possible. One of the best incentives is to include staff and family members who may be visiting at that time. LTC facilities seek assistance from the local community to provide scheduled activities for residents, such as church services to be held in the facility chapel, vocal and instrumental talent sessions, monthly birthday celebrations, holiday parties, and visits by children's groups, such as school classes, Bible-school classes, and Girl Scout and Boy Scout troops. Visits by children seem to be especially enjoyed and appreciated by the residents. Another good activity that has proved to be very therapeutic is pet therapy. Kittens, puppies, baby lambs, rabbits, or other small animals are scheduled to be brought in for petting and cuddling once or twice a month. Aquariums set up in the lobby or television area are another treat for residents and sometimes have a calming effect on residents experiencing an emotional event. Medications As with acute care, most LTC residents will have ordered medications that you will administer and document. Remember that elders will often have stronger reactions to medications and are more at risk for toxicity because the kidneys and liver are unable to rid the body of the drug as quickly as younger adults do. Safety: Be vigilant in assessing for oversedation and toxicity in these residents. Vital Signs Rather than assessing vital signs a minimum of three times per day as in acute care, vital signs are routinely assessed once a week or once a month, according to the facility's policy. If the resident exhibits signs or symptoms of illness or suffers an injury, vital signs are assessed more frequently for a period of time, as determined by the resident's condition and the facility's policy. Safety: When you administer medications to residents who require assessment of blood pressure or pulse, you will always check to be sure these vital signs fall within stated parameters before administering the medication. DocumentationTerm Care Nursing While the aging process has the advantages of wisdom, more life experiences, and new and different opportunities, it also sometimes involves the loss of ability to live independently because of health problems, whether physical or mental. Many older adults may find it necessary to live in assisted living facilities or long-term care (LTC) facilities, more commonly known as nursing homes. You probably will have the opportunity to perform some of your clinical experiences in an LTC facility, and you will find that providing nursing care for these individuals is vastly different from the care you provide in an acute care setting. One difference is how you refer to those for whom you provide care. Patient or Resident? You typically refer to the population within acute care facilities as patients or clients. Those individuals are in the facility temporarily because they require some type of diagnostics or treatment for health problems. Most individuals for whom you will provide care in LTC facilities are not there temporarily; they reside, or live, there. The facility is their actual home, their residence, and their place of refuge from society, although many of them would prefer to live somewhere else if they could. It is considered more appropriate to refer to these individuals as residents rather than patients. Residents' Needs Using the term resident may help you to maintain the focus of your role in providing nursing care. Even though an acute care patient and an LTC resident may have some of the same needs, you will have additional opportunities to meet more needs in the LTC setting. In acute care, you prioritize needs according to Maslow's hierarchy of needs, but it is performed within a much smaller time frame than in an LTC facility and may not require you to address needs from every level. When you care for patients in an LTC facility, your primary focus will be to provide ongoing life services for the residents—those things we all need and desire, which address all levels of Maslow's hierarchy of needs: • Oxygen and fresh air, water and nutrition, healthy elimination • Rest and sleep, comfort and pain relief • Optimal health • Safety and security • Spiritual edification • Freedom from anxiety and fear • Love and affection, acceptance by others • Self-respect and being respected • Self-esteem and self-confidence • Productivity and self-worth • Simple enjoyment and fulfillment in daily life Helping to Meet These Needs You will have ample chances to meet more of these needs than you will probably ever realize. When you enter an LTC facility, you have a unique opportunity to impact the lives of the residents and a chance to make their days brighter and more fulfilling. You have the opportunity to bring compassion, respect, comfort, and affection while you provide nursing care. One of the benefits for you is the opportunity to learn from a wealth of wisdom that the residents have to share. Many of them will have lived and experienced decades of life beyond that of the typical student. We all can learn from the older and wiser generations if we are willing. Encourage residents to reminisce and tell about events they have experienced. Listen attentively as you get to know the resident better, and you may gain knowledge or develop a better appreciation for the past. You also might enjoy it. The LTC setting is different from acute care in a variety of ways: the contents of rooms, personal attire, personal care, nutrition and hydration, elimination and toileting, immobility and activity, medications, assessment, and documentation. Resident Rooms Because LTC residents are living in the facility rather than spending a day or two there, it is important to remember that their rooms are their personal residences. It is even more important that you knock before entering their room, just like you do before entering someone's house. Residents may bring personal items, sometimes even pieces of furniture, to personalize their residence. Encourage residents to hang photographs and the artwork of grandchildren or other significant young ones. Use personal blankets, pillows, and afghans when available. Provide whatever assistance is required to keep the room, floor, and bathroom clean, but allow the resident to arrange his or her possessions as desired. It may look cluttered to you, but it may be just the way he or she wants it. Offer to help organize or straighten articles if the resident requires or desires assistance. If the resident is immobile or has severe dementia, it will be your responsibility to maintain the room's appearance and organization so that safety is not sacrificed. Personal Attire The resident wears his or her own clothing and shoes, unless the resident's condition is such that he or she requires continual medical and nursing intervention that is hindered by wearing personal clothing. Assist the resident as needed to get dressed each morning. If the resident is incontinent, change his or her clothing immediately. Families of residents may or may not prefer to do the resident's personal laundry. Some residents will require that the LTC facility employees launder their clothing. If this is the case, it is important for the resident's name to be written with a permanent marker on the label or inside the neck of the garment. Even socks and underwear must be marked to prevent misplacing articles of clothing in another resident's laundry. Safety: Make certain that residents' shoes have nonskid soles to decrease the risk of falls. If the soles are somewhat slick, it is helpful to apply several strips of adhesive tape across the soles of the shoes. The cloth side of the tape helps prevent slipping on a tile floor. Personal Care Some residents may be able to perform their daily hygiene without assistance, but many will need assistance. For these residents, you will provide personal care, but on a slightly different schedule than in acute care. For example, most residents will not take a complete bath every day. Aging skin becomes drier and more fragile, so many residents will prefer to take a complete tub bath or shower only two to three times per week. On nonbath days you will wash the resident's face, hands, feet, and perineal area daily and as needed. Most facilities have shower rooms or tub rooms, with several tubs and shower stalls, which must be shared by all the residents. Safety: You will need to disinfect shower chairs, tubs, and mechanical lifts after each use. This is paramount to prevent cross-contamination. Without stringent disinfection between residents, it is possible to spread diseases caused by highly contagious organisms such as Clostridium difficile (C. diff.). This bacterium causes severe diarrhea that has the potential to be fatal in elderly and immune-suppressed individuals, and it can spread quickly throughout a facility. Provide privacy for the residents by pulling the curtains between the bathing stations and ensure that the doors are kept closed while bathing facilities are in use. Safety: Immediately mop up all water that is splashed or dripped onto the floor to prevent falls. Whirlpool tubs are commonly used for bathing, providing the additional benefit of stimulating the circulation and débriding any wounds the resident may have. Safety is a real issue when bathing residents. It would be easy for residents with impaired mobility or dementia to drown in a whirlpool tub because of the depth of water. Safety: Never leave a resident unattended while he or she is bathing! Environmental temperature must be kept warm enough that the resident will not become chilled. Some residents are unable to stand or access the bathtub or whirlpool tub without the use of a mechanical lift. You learned about safe usage of this equipment in Chapter 16. Safety: Remember to obtain an adequate number of coworkers to provide safe handling while transferring residents via a mechanical lift. Provide hair care for residents on a daily basis, and wash their hair at least once a week or more often if needed. Many LTC facilities have beauty and barber shops, allowing residents to schedule appointments with professional stylists. If the facility does not have these types of services available or if residents do not have someone who assists them in these matters, you will assist with styling their hair. It will help you to meet this need more easily if you think how you would feel if you were unable to perform these activities and no one else cared enough to assist you. Everyone wants to look their best to receive friends and loved ones when they come to visit; appearance is part of self-esteem. Male residents may require assistance with shaving, some daily and others only two to three times per week. Safety: If a resident has supplemental oxygen being delivered, turn it off for at least 10 minutes before shaving with an electric razor to allow the higher oxygen levels in the room air to dissipate. If the resident cannot tolerate the removal of oxygen for that length of time, you will use a safety razor. Safety: Before using a safety razor, assess whether the resident is taking anticoagulants such as warfarin (Coumadin), which would put the resident at risk for excessive bleeding in the event you accidentally nick his skin. Follow the facility's policy regarding the use of electric and safety razors. You will perform nail care more frequently in an LTC facility than in an acute care setting. Follow the facility's policy carefully regarding who may cut or trim nails, especially those of a resident with diabetes or peripheral vascular disease (refer to Chapter 15). Nutrition and Hydration Although you provide meals, snacks, and fluids to patients in acute care, the responsibility is more extensive in an LTC facility. It is your responsibility to make certain that each resident maintains adequate dietary intake by: • Ensuring that dentures are inserted for meals • Assessing whether the food needs to be finely chopped or pureed • Feeding or assisting the resident to eat, as needed • Monitoring and recording the percentage eaten at each meal • Ensuring that adequate fluids are ingested, usually a minimum of 1500 mL/day • Providing supplemental protein and carbohydrate drinks as needed • Monitoring for weight loss on a weekly or monthly basis Most LTC facilities have a policy addressing interventions to implement when a resident eats 50% or less of the food served for a meal. The most common intervention is to provide a supplemental nutrition drink, such as Ensure, between meals. Accrediting agencies look for documentation that this has been done. It is important that all residents who are able be taken to the dining room for each meal. Meals are a social event for most people, and this gathering allows residents to see, greet, and converse with their neighbors. Figure 32-6 shows residents socializing during a meal. For residents who are immobile, it is even more important to transfer them to the dining room for all three meals each day so that they have more opportunity to interact with others. You may transfer residents via a wheelchair or a special chair called a geri-chair. A geri-chair is a recliner with side arms, a lap belt, and wheels so that it can be navigated through the hallways. It is used for residents who are unable to sit unassisted. Figure 32-6 These residents are socializing during a meal. (PunchStock.) The dining room in most facilities contains multiple tables with assigned seats for each resident. This allows the staff to deliver special diets to the correct residents. Safety: Always check the resident's meal card and diet before delivering the tray to the resident. When a resident is unable to feed himself or herself, you must assist him or her. It is important to sit in a chair next to the resident, rather than to stand. This puts you at eye level with the resident, which improves communication and allows the resident to see your face. Some residents are unable to look upward to see someone standing, towering above them. It is important to make mealtimes as pleasant as possible. Converse with the residents and include them in conversations whether or not they are able to verbalize. Try to make the mealtime a happy and social time, as it can be in the home with one's family. Elimination and Toileting Not all residents in an LTC facility are incontinent of bowel and bladder, but many will be. Check incontinent residents every 1 to 2 hours for the need to be changed. Avoid allowing a resident to lie or sit in wet or dirty clothes or linens. Change them as needed, and provide scrupulous perineal and skin care to prevent skin breakdown. Some residents may require barrier ointments to aid in protecting the skin from urine and feces. Avoid using the term diaper for incontinence briefs. Treat the resident with respect when you are changing the brief and washing the perineum after incontinence. It is important to monitor and record whether or not each resident has a bowel movement on every shift. Residents with impaired mobility are particularly at risk for constipation. Most facilities have a policy requiring that each resident be provided with a stool softener or laxative if the resident does not have a bowel movement at least every 3 days. Careless tracking of daily bowel movements can result in fecal impaction, which is a very uncomfortable condition for the resident. (See Chapter 30 for more information about fecal impaction.) Immobility Residents can develop impaired mobility if you do not take action to prevent it. Encourage residents to get out of their rooms and to ambulate as much as possible. Encourage participation in exercise sessions and outdoor walks. Encourage those with gardening interests to help tend to the flower gardens if they are physically able. Lead groups of residents in chair exercises, which can help prevent loss of strength and preserve joint mobility. Frequently reposition bedfast residents and those who are restricted to sitting in a chair and unable to walk. The longest any resident should remain in any one position is 2 hours. Repositioning, assessing pressure points for erythema, and applying lotion as needed are paramount to preventing pressure ulcers. Encourage residents, if they are able to do so, to sit in a chair for meals and to attend social events. Provide passive and active range-of-motion exercises for bedfast residents to increase circulation and to prevent atrophy of muscles and contracture formation. Exercises should be performed at least once or twice per shift during daytime hours. Also encourage the resident to do as much as he or she is able to do with regard to activities of daily living (ADLs). For example, if a resident is only able to wash his or her face and hands and brush his or her teeth and hair, encourage the resident to do so. Avoid doing it all yourself in an effort to "get done" because you are busy. Participation in self-care helps to increase activity but also fosters confidence, independence, and self-esteem. Activity and Entertainment Most LTC facilities schedule regular activities for the residents to participate in as they are able. Some examples include: • Craft-making sessions • Manicure sessions • Domino tournaments • Group singing and karaoke • Movie time • Current event discussion groups • Daily reading aloud of the newspaper or Bible • Paint-by-number pictures, watercolors, and finger painting • Bingo • Ice cream socials • Book time, where a novel is read aloud each session until completed Some LTC facilities may include music sessions in which residents are provided with instruments to play in accompaniment to someone playing the piano. Instruments may include triangles, cymbals, sticks, bells, tambourines, small hand drums, kazoos, or harmonicas. Encourage residents to participate in as many of these activities as possible. One of the best incentives is to include staff and family members who may be visiting at that time. LTC facilities seek assistance from the local community to provide scheduled activities for residents, such as church services to be held in the facility chapel, vocal and instrumental talent sessions, monthly birthday celebrations, holiday parties, and visits by children's groups, such as school classes, Bible-school classes, and Girl Scout and Boy Scout troops. Visits by children seem to be especially enjoyed and appreciated by the residents. Another good activity that has proved to be very therapeutic is pet therapy. Kittens, puppies, baby lambs, rabbits, or other small animals are scheduled to be brought in for petting and cuddling once or twice a month. Aquariums set up in the lobby or television area are another treat for residents and sometimes have a calming effect on residents experiencing an emotional event. Medications As with acute care, most LTC residents will have ordered medications that you will administer and document. Remember that elders will often have stronger reactions to medications and are more at risk for toxicity because the kidneys and liver are unable to rid the body of the drug as quickly as younger adults do. Safety: Be vigilant in assessing for oversedation and toxicity in these residents. Vital Signs Rather than assessing vital signs a minimum of three times per day as in acute care, vital signs are routinely assessed once a week or once a month, according to the facility's policy. If the resident exhibits signs or symptoms of illness or suffers an injury, vital signs are assessed more frequently for a period of time, as determined by the resident's condition and the facility's policy. Safety: When you administer medications to residents who require assessment of blood pressure or pulse, you will always check to be sure these vital signs fall within stated parameters before administering the medication. Documentation

defensemechanisms

Mechanism Description Examples Overuse Can Lead To Denial Unconscious refusal to see reality Usually the first defense learned and used Is not consciously lying The alcoholic states, "I can quit any time I want to." Repression, dissociative disorders Repression (stuffing) An unconscious "burying" or "forgetting" mechanism Excludes or withholds from our consciousness events or situations that are unbearable; a step deeper than "denial" "Forgetting" a loved one's birthday after a fight Dissociation Painful events or situations are separated or dissociated from the conscious mind Patients will often say, "I had an out-of-body experience" or "it happened to someone else, but it was as though it happened to me" Patient who had been sexually abused as a child describes the situation as if it happened to a friend or a sibling. Police visit parent to inform parent of death of child in car accident. Parent tells police, "That's impossible. My child is upstairs asleep. You must have the wrong house." One of the dissociative disorders, such as multiple personality disorder Rationalization Use of a logical-sounding excuse to cover up true thoughts and feelings The most frequently used defense mechanism "I did not make a medication error; I followed the physician's order." "I failed the test because the teacher wrote bad questions." Self-deception Compensation Making up for something we perceive as an inadequacy by developing some other desirable trait The small boy who wants to be a basketball center instead becomes an honor roll student The physically unattractive person who wants to model instead becomes a famous designer Reaction formation (overcompensation) Similar to compensation, except the person usually develops the exact opposite trait The small boy who wants to be a basketball center instead becomes an honor roll student The physically unattractive person who wants to model speaks out for eliminating beauty pageants Failure to resolve internal conflicts Regression Emotionally returning to an earlier time in life when there was far less stress Commonly seen in patients while hospitalized (Note: Everyone does not go back to the same developmental age. This is highly individualized.) Children who are toilet trained begin to wet themselves Adults may start crying and have a "temper tantrum" May interfere with perception of reality May interfere with progression and development of personality Sublimation Unacceptable traits or characteristics are diverted into acceptable traits or characteristics Burglar teaches home safety classes Person who is potentially physically abusive becomes professional sports figure People who choose to not have children run a day-care center The "socially accepted" behavior might actually reinforce the negative tendencies, and the person may still show signs of the undesirable behavior or trait Projection (scapegoating) Blaming others A mental or verbal "finger-pointing" at another for the problem "I didn't get the promotion because you don't like me." "I'm overweight because you make me nervous." Finds faults in everything and everyone Fails to learn to take personal responsibility May develop into delusional tendencies Displacement (transference) Transferring anger and hostility to another person or object that is perceived to be less powerful: the "kick-the-dog syndrome" Parent loses job without notice; goes home and verbally abuses spouse, who unjustly punishes child, who hits the dog Loss of friends and relationships Confusion in communication Restitution (undoing) Making amends for a behavior one thinks is unacceptable Making an attempt at reducing guilt Giving a treat to a child who is being punished for a wrongdoing The person who sees someone lose a wallet with a large amount of cash does not return the wallet but puts extra money in the collection plate at the next church service May send double messages Relieves the "doer" of the responsibility of being honest in the situation Isolation Emotion that is separated from the original feeling "I wasn't really angry; just a little upset." Avoids dealing with true feeling Can increase stress Conversion reaction Anxiety is channeled into physical symptoms (Note: Often, the symptoms disappear soon after the threat is over.) Nausea develops the night before a major examination, causing the person to miss the examination. Nausea may disappear soon after the scheduled test is finished. Anxiety not dealt with can lead to actual physical disorders such as gastric ulcers and possibly some cancers Avoidance Unconsciously staying away from events or situations that might open feelings of aggression or anxiety "I can't go to the class reunion tonight. I'm just so tired. I have to sleep." Adapted from Wilkinson JM, Treas LS. Fundamentals of Nursing, Vol. 2, 2nd ed. Philadelphia: FA Davis; 2011:585-586; Vol. 1, Table 25-1. Wilkinson table notes the following source: Adapted from Neeb K. Fundamentals of Mental Health Nursing (4th ed) Philadelphia: FA Davis; 2014. Box 7-3 Symptoms of Stress When you are experiencing stress, you may have a few or a number of these symptoms: • Frequent feelings of anger, helplessness, or hopelessness • Headaches, back pain, and insomnia • Hiding real feelings from family and friends • Hurting loved ones with words or physical harm • Constant worry, memory loss, and trouble thinking clearly • Panic attacks with rapid heart rate, shortness of breath, and dizziness • Isolation from friends and family • Inability to make decisions • Overuse of alcohol, drugs, or food to feel better

med staff

Medical Doctor Doctor of Osteopathy Responsible for diagnosing and treating disease, illness, and injury; ordering diets, tests, medications, treatments, therapies, and procedures; and directing overall care of patients Physician's Assistant (PA) Employed by a physician or hospital to work closely with the physician and assist in directing patient care

public health insurance

Medicare As discussed at the beginning of this chapter, Medicare is the federal government's acute care health insurance program for people older than 65 years. It also is available to disabled individuals younger than 65 years, individuals with end-stage renal disease, and those with certain debilitating illnesses. Medicare includes four programs, which are described in Box 2-2. Medicare uses a payment schedule based on diagnosis-related groups (DRGs). These classifications of illnesses and diseases are used to determine the amount of money paid by Medicare to the hospital for the care of a patient with that particular illness or disease. For example, a patient might be admitted to the hospital with diabetes. According to the DRGs, Medicare will pay the hospital a certain amount for the care of this diabetic patient, which includes all nursing care, tests, treatments, and teaching. If the patient stays in the hospital longer than the allowed time or it costs the hospital more than the set amount for the patient's care, the payment will still be the set amount of the DRG. If the patient has complicating factors that affect the hospital stay, for example, the patient gets an infection or develops a new problem in addition to diabetes, the hospital can submit bills for the additional problems under a different DRG.Medicaid Medicaid is a federal-state government matching funding program. Because the state is required to set coverage policies and administer the program, the benefits are slightly different in each state. This program offers assistance for poor and medically indigent individuals, pregnant women with an income below the poverty level, and children and certain disabled individuals who meet income-level requirements. Indian Health Service The Indian Health Service (IHS) provides government funding for health care for qualified Native American individuals. The IHS may fund hospitals, ambulatory medical and mental health-care clinics, and dental care facilities. It may contract with one or more of the federally recognized tribes to fund health-care services in that tribe's reservation territory. Individuals utilizing these health-care services must meet criteria for a "certificate of degree of Indian blood (CDIB)" in order to be eligible to receive care. A CDIB card is issued when an individual meets the criteria set by the tribe. This card enables the individual to receive health-care services at tribal and IHS facilities.

the wellness illness continuum

Most of us are not completely well or completely ill at any given time. Rather, we move up and down along a continuum, or scale, with exceptional wellness at the top and severe illness at the bottom. Even within a day, a person may move up or down on this continuum. For example, you may wake up with a sore throat and nasal congestion and you might consider yourself at 5 on the continuum. By afternoon, you are feeling better and may move up the scale to 7. It is important to remember that physical health is not the only issue that is involved when discussing wellness and illness. A person may be well physically but may be depressed or have other mental conditions that would prevent him or her from being considered healthy. However, if a mental illness is being treated and managed well, the person moves closer to the exceptional wellness end of the scale.

nursing staff

Nurse Practitioner (NP) Masters rn certified in a specific area of practice diagnoses illnesses and prescribes medications and treatments for them Registered Nurse (RN) Practices nursing within a defined scope under the direction of a physician; provides direct patient care, manages departments, and supervises other nurses and assistive personnel Licensed Practical/Vocational Nurse (LPN/LVN) Practices within a defined scope under the supervision of a physician, dentist, or RN; provides direct patient care and supervises assistive personnel Unlicensed Assistive Personnel (UAP) Performs more complicated tasks, including sterile procedures, in some states Certified Nursing Assistant (CNA) Perform patient care duties and assist nursing staff

lab staff

Pathologist (MD) Medical doctor examines tissue and blood samples to determine the origin or existence of disease Medical Laboratory Technologist (MLT) Medical Technician (MT) Examines and analyzes body fluids and tissues, matches blood for transfusions, and tests for blood levels of medications Phlebotomist Draws blood specimens from patients for testing

radiology staff

Radiology Staff Radiologist (MD) Medical doctor who specializes in procedures involving x-rays and radiation therapy; reads radiographs and other radiological films Radiologic Technologist (Rad Tech) Operates x-ray machines and other radiological equipment, such as computed tomography (CT) scanners, as well as magnetic resonance imaging (MRI) and ultrasound equipment; assists the radiologist by performing ordered tests to determine diagnoses and treat certain diseases

therapy staff

Respiratory Therapist (RT) Respiratory Therapy Technician Evaluates, treats, and cares for patients with breathing problems due to heart and lung disease RTT generally works under the supervision of an RT Physical Therapist (PT) Physical Therapy Assistant (PTA) Provides services to help improve or restore function and mobility, relieve pain, and prevent or limit permanent physical disabilities for patients suffering from injuries and disease PTA generally works under the supervision of a PT and carries out the PT's orders Speech and Language Therapist (ST) Assesses, diagnoses, treats, and helps to prevent disorders related to speech, language, voice, swallowing, and fluency Occupational Therapist (OT) Certified Occupation Therapy Assistant (COTA) Assists patients with disabilities to develop, recover, or maintain their skills for daily activities and work

the aging population and nursing

The Aging Population and Nursing According to the National Institute on Aging, it is anticipated that by 2030, 1 in every 5 U.S. citizens will be elderly, and seven million citizens will be older than 85 years. This means that there will be an increasing need for more nurses. Despite this, the Health Resources and Services Administration projects that the supply of nurses in the United States will fall by more than one million below the requirements needed to care for the population in the year 2020 unless extensive intervention is accomplished to recruit and retain more nurses. Knowledge Connection What are the differences between the young-old, the middle-old, and the old-old? Are there similarities you can identify? Misconceptions About Aging It is not uncommon for others to categorize elderly people according to invalid assumptions. For example, some might stereotype elderly individuals as kind and nurturing, like doting grandparents. Other people, based on different experiences, might generalize that elderly people are confused, incompetent, or incapable of caring for themselves. Consider the many derogatory perceptions that people in today's society have of elders: Old people are hard of hearing, senile, confused, unhappy, depressed, in poor health, forgetful, cranky, and boring. Elderly people are often seen as afterthoughts, incapable of having their own interests, desires, friendships, or activities. This practice of discrimination and prejudice against elders is referred to as ageism. The practice of ageism contributes to stereotyping, unequal treatment in the workforce, and denial of health care. It is important to treat all patients as individuals, with unique characteristics and personalities, no matter the age of the patient. It is true that many of the patients you will care for will be elderly. Some may be confused and cranky, while others may be gentle and kind. In fact, your elderly patients will be quite similar to your younger patients, each one with different concerns and needs. It is never appropriate to practice ageism; rather, your purpose is to see your patients as individuals and to provide whole-person care. Some individuals may resort to ageism because of a lack of knowledge about elders. Many traditional myths about elders are easily proven to be incorrect. When you care for elderly individuals, first assess their state of health, their psychological well-being, and their own perceptions of their abilities. The old adage, "You are only as old as you feel," is true. Numerous people who fall into categorization of "young-old," "middle-old," or "old-old" are younger in health, mind, and spirit than people of a much younger chronological age. Your nursing care should always be personalized, based on the needs of the individual and not on your assumptions about a person based on his or her age.

skilled nursing facility

The SNF provides a less intense level of care than that found in a traditional or long-term acute care hospital. It usually is a transitional care setting. Patients may stay in an SNF for a few days or as long as 100 days, but they eventually move to a rehabilitation, nursing home, or home-care setting. SNF care consists of skilled nursing care and physical, occupational, and speech therapy as needed. Physicians usually do not visit daily and are more likely to see patients on a weekly basis. Laboratory, radiology, or surgical services usually are not available at an SNF. An SNF level of care usually is covered by Medicare and most private insurers, but there are certain requirements: • The patient must have been hospitalized for at least 3 days prior to admission. • The patient must enter the nursing home within 30 days of a hospitalization. • There is a 100-day stay maximum per year related to any one hospitalization and diagnosis. • The patient must be making regular progress as documented by the medical professionals. An example of the effective use of this level of care is a situation in which an elderly man falls at home and suffers a fractured hip. While in the acute care hospital, he has surgery to repair the fracture but does not want to eat after surgery. Eventually a feeding tube is placed, and the patient is fed through the tube. He begins to eat a bit, but not enough to take out the tube. The surgery was successful, but the patient is not strong enough to return home. He is placed in an SNF unit for skilled nursing care. He continues to increase his oral intake and is discharged to his home in 40 days.

case management

The delivery of nursing care via a case management system is associated with a managed care strategy. The nurses providing case management services act simultaneously as coordinators, facilitators, impartial advocates, and educators. These case managers can be found in hospitals, rehabilitation facilities, and home health agencies. They handle workers' compensation claims resulting from severe injury or disability. The process of case management involves seeing each patient as an individual and each situation as unique. The goal of case management is to assist patients who are vulnerable, at risk, or cost-intensive so that their care is coordinated, meets their specific needs, and is cost-effective while still bringing them to optimum health. An example of case management is a nurse employed by an insurance company who is managing the care of a patient who was injured in a bridge collapse, resulting in numerous broken bones. The hospital nearest the bridge is a small rural hospital without specialty care for orthopedics or bone specialists. The patient was taken there because it was the closest facility. The case manager arranges for the stable patient to be transferred to an appropriate specialty unit in a nearby city via helicopter. At that facility, the patient's injuries are quickly evaluated and treated. In a short time, the case manager arranges for the patient to be transferred to a rehabilitation facility that specializes in multiple trauma. The patient gets the best possible care for his injuries and quickly moves into rehabilitation because the case manager was able to locate the most appropriate facilities for the patient and arrange to have him treated there. Case managers may supervise the care of a group of patients within one facility, such as an acute care hospital or home health agency. In that situation, the case manager ensures that each assigned patient is receiving cost-effective care while reaching the goals of a return to optimal health and function. A disadvantage of this type of nursing delivery is that case managers' options may be limited, depending on the availability of adequate facilities and funding to move the patient to the optimum facility.

charitable organization

There are also local, state, and national charitable organizations that provide free health-care services to individuals. These organizations may be funded by religious denominations, private individuals, or national or community organizations such as the Catholic and Jewish health systems, Shriners, the Kaiser family, and the Robert Wood Johnson Foundation, just to name a few.

private health insurance

When a person uses private health insurance, he or she, known as the beneficiary, pays premiums to the insurance company. When the beneficiary is cared for by a physician or hospital and the bill is sent to the insurance company, the insurance company is referred to as a third party or a third-party payer. Blue Cross Blue Shield, Aetna, United Healthcare, and Prudential are a few of the largest private health insurance companies currently operating in the United States. Private health insurance companies offer several types of health insurance plans and services. Box 2-3 provides a brief explanation of the most common types. The development of these plans came about as a strategy to help contain the cost of health care by restricting patients' access to only those groups of health-care providers who have contracted to provide specific services at a negotiated price. Capitation refers to the payment system used by health maintenance organizations (HMOs). In this system, primary care physicians (PCPs) are paid a set amount per member per month to manage the health care of those members. This PCP is considered the gatekeeper to health services for the individual enrolled in the HMO. For example, a PCP may have 200 patients assigned to him or her. Perhaps the set amount per member is $40. The PCP is paid $8000 per month to see all the patients who make appointments and perhaps to make hospital rounds as well. If the PCP is unable to successfully treat the patient's condition, he or she makes a referral to a specialist. The patient cannot self-refer, and the specialist cannot accept the patient without a referral. In this way, access to more costly care and potentially redundant testing is controlled.Private health insurance is available in different venues. Individuals may participate in group health insurance plans provided by employers. With this type of health insurance, the employer pays a portion or all of the cost of the premium. The company may offer one type of health plan or may offer a variety of plans, and the individual can choose from several types of coverage for different prices. The employer decides what types of policies are available to the employee. The options available to the employer include HMO, preferred provider organization (PPO), and point-of-service (POS) plans. The company may also define and fund its own benefits and have a health insurance company administer the benefits according to the employer's defined requirements. The employer generally negotiates with the health insurance company to utilize their HMO, PPO, or POS networks to provide health-care services to their members

effectsofstressonillness

When stress is continuous, it causes the sympathetic nervous system to go into "overdrive." Constricted blood vessels and increased heart rate can lead to hypertension and heart disease. Vasodilation in the brain may contribute to migraine headaches. Illness and hospitalization also are stressors that can worsen some conditions, such as diabetes. In fact, research has shown that simply being admitted to the hospital will increase most individuals' blood glucose levels even though they do not have diabetes. Stress also can cause exacerbations in patient with some chronic disorders, such as systemic lupus erythematosus, multiple sclerosis, fibromyalgia, arthritis, and asthma. When a family member has a major illness, it inflicts stress on the healthy members of the family because of concerns over the cost of health care, the care the patient is receiving, and fear of the ultimate outcome. It is vital that nurses be aware of all the stressors that both the patient and family members are facing. Recognizing the Symptoms of Stress How many times have you heard a coworker or fellow student say, "I am so stressed out"? It is a common phrase, and it sounds as if we all know when we are stressed. However, that is not always the case. Some people do not realize that they are experiencing severe stress overload until they are very ill or have caused damage to relationships. Box 7-3 lists some symptoms of stress. Stress Management Coping strategies, the actions people utilize to combat stress, vary from person to person. It is important to note that both positive and negative coping strategies exist. Negative strategies cause harm to yourself or others—for example, drinking too much or kicking the cat. Positive strategies include those that are good for body, mind, and spirit. Examples of positive coping strategies for the body include: • Eating regular meals with lower levels of fat and sugar • Exercising regularly • Sleeping an adequate number of hours every night • Using deep breathing exercises to relax and relieve stress • Listening to your body and giving it what it needs, such as extra rest when you are ill Examples of positive coping strategies for the mind and spirit include: • Saying "no" to people when necessary, preventing yourself from taking on more responsibility than you can handle • Taking time out to relax and have fun with family and friends • Laughing • Reducing excesses in your life; getting rid of clutter both in activities and in possessions • Talking about your feelings with people you trust • Asking for help when you need it • Participating in worship services or spending time with nature • Taking a "mental vacation" from time to time. Close your eyes and picture a beautiful, relaxing place. Imagine yourself there. What are you doing? What do you see? What do you hear? What do you smell? • Keeping a journal, either of daily life or of stressful events and your response to them Stress is a fact in our daily lives. It is not going to go away. We get to choose how we will respond to it. If you choose to use positive coping strategies, your life will not be ruled by stress.

a nurse at an ophthalmology clinics caring for a pt. the nurse is interviewing a client who was referred by her dr. for suspicions of cataract. which of the following client reports should the nurse recognize is consistent with the primary care providers suspicion?

eyestrain and headache with close work? halos and rainbows when looking at lights? bright flashes of lights and floaters? loss of peripheral vision? answers b

stress and adaptation

ccording to Hans Selye, who developed the response-based model of stress, stress is identified as a nonspecific response of the body to any demand made on it. Any stress-inducing event is referred to as a stressor; it can include a physical, emotional, pleasant, or unpleasant occurrence. How these stresses of daily life affect an individual depends largely on the individual's ability to adapt. Adaptation is the ability to positively adjust to changes that occur in an individual's world. If one does not adapt to changes, the physiological and psychological responses can be harmful. Ongoing stress not only can result in illness and injury but also can lead to death if it is not relieved. Modifiable Risk Factors for Selected Diseases Risk Factor Diseases Obesity Diabetes, heart disease, breast cancer, colon cancer Diet high in trans-fatty acids, cholesterol, and triglycerides Diabetes, stroke, heart disease Hypertension Stroke, heart disease, kidney disease Smoking Heart disease, bronchitis, chronic obstructive pulmonary disease (COPD), stroke, lung cancer, and other types of cancer The Seven Warning Signs of Cancer The first letter of each sign indicating that a condition may be cancerous together spell out the word CAUTION. • C hange in bowel or bladder habits • A sore that does not heal • U nusual bleeding or discharge from any body orifice • T hickening or a lump in the breast or elsewhere • I ndigestion or difficulty in swallowing • O bvious change in a wart or mole • N agging cough or hoarseness Anatomy and Physiology Connection The Fight-or-Flight Response When your brain perceives a threat to your well-being, it sends messages to the body to prepare to either stay and fight or run away. This innate protective response saved our ancestors from wild animals and other predators and is known as the fight-or-flight response. Your brain engages the sympathetic nervous system, which stimulates the endocrine glands to pump cortisol, adrenaline, and other hormones into the bloodstream, enabling you to hit harder, jump higher, see farther, and think or run faster. These hormones cause the bronchial airways to dilate and the respiratory rate to rise, which both help to increase oxygen intake. The hormones also cause the heart rate to increase, blood vessels in the skin to constrict, and central blood vessels to dilate in an effort to deliver more oxygen-rich blood to the brain, heart, and muscles needed for the fight-or-flight response. Glycogen is converted to glucose to provide additional fuel and energy. The pupils of the eyes dilate to allow better vision. The sense of hearing is heightened to detect warning sounds. Salivary glands decrease their secretions and peristalsis slows in the digestive tract to prevent the need for bowel elimination during this "emergency" or high-stress time. Arm and leg muscles tense in preparation for running or physical fighting. When the threat is removed, the parasympathetic nervous system dominates and reverses these responses. Selye's theory of stress and illness probably has been demonstrated at some time in your life when you were in a situation of ongoing, unrelieved stress and then developed an illness. When we are stressed, our body responds with the fight-or-flight response described in the Anatomy and Physiology Connection. This is referred to as the alarm phase. If the stressor is removed in a relatively short period of time, our bodies return to normal. However, if the stressor continues in our life and we do not find positive ways of relieving it, our bodies get stuck in that fight-or-flight response, producing high levels of cortisol and other stress hormones. The body works hard trying to resist the threats of stress and to keep working efficiently to prevent illness. Selye calls this the resistance phase, and it can continue for weeks, months, or years. Eventually, our bodies cannot keep up the pace of dealing with stressors and fighting off illness. This is the exhaustion phase, when the body's resources are depleted and we are most vulnerable to physical and psychological disease. Selye titled this the general adaptation syndrome (GAS) because it describes the body's attempts to adapt to the stressors we encounter. Stress can be considered either negative or positive, but the body cannot tell the difference between the two. Negative stress has the potential to cause harm. Examples would be physical illness, disease, or death of a family member. Positive stress involves events that, although anticipated, still may be viewed as stressful. Examples would include an upcoming marriage, job change, or graduation. People use different ways of coping to manage their stressors. The possible outcomes of stress and ways of coping are changing the stressor, adapting to the stressor by changing thoughts and behaviors related to it, or avoiding the stressor. If the stressor—or in many cases a variety of stressors— remains in place without the person adapting to it, the stressor eventually causes illness or even death. When a person is dealing with several stressors at one time or a stressor that lasts for a long time, it is much more difficult for him or her to adapt. Your response to stressors depends on several factors: • How do you view the stressor? Do you see it as something major or something that can be adapted to with increased time and energy? • What is your current health status? Do you already have a chronic illness such as diabetes or hypertension? Are you constantly in a state of exhaustion with few energy reserves? • What are your support systems? Do you have friends and family who can help you with the details of life so that you can use your energy to adapt to the stressor? Do you have people to listen to you when you need to talk about your stressors? • What other factors are at play? Your age, life stage, and life experiences can influence your ability to adapt to your stressors. The outcome of stress is that either you adapt to it or you develop a disease or illness. Our bodies use various feedback mechanisms to maintain homeostasis, or balance in the internal environment of the body. These are physiological responses and include GAS. The process of making changes, physical or psychological, in response to stress is adaptation. The psychological response to stressors includes feelings, thoughts, and behaviors. Common responses are fear and anxiety. Anxiety is a vague, uneasy feeling that is not centered on a specific source, and it is emotional in nature. Fear is an identified danger or threat with a real or imagined source, and it is cognitive in nature. One way we manage our fears and anxieties is by using defense mechanisms, which are unconscious reactions to decrease the stress. They help decrease tension caused by various stressors in our lives.

clientcenteredcare

empowers the patient to take control of and manage his or her care. This type of system is often seen in a rehabilitation setting. It allows patients to achieve independence within the limits of their disability by permitting them to have a voice in their rehabilitation, schedule, goals, and method of attaining those goals. Client-centered care in the acute care hospital setting varies. In that setting, the goal is to decrease the number of people who give care to the patient so that there is less chance of miscommunication or error, and to provide care as soon as it is needed instead of having to wait for people from different departments to arrive. Health-care workers are cross-trained to perform as many tasks as possible for each patient. For example, in some client-centered care settings, the nurse not only performs the usual nursing care but also obtains needed blood specimens, runs an electrocardiogram (EKG, a tracing of electrical heart activity) when indicated, and even may administer respiratory therapy treatments. In this situation, no phlebotomist comes in to draw blood, no EKG technician is requested if the patient is having chest pain, and no respiratory therapy technician is needed to give a breathing treatment. One disadvantage of this type of care in the acute care hospital is the time and education needed for each staff member to cross-train in all of these areas.

ltc

facilities provide 24-hour custodial care and some medical services for patients with chronic illness or disability, particularly older people who have mobility and eating problems who cannot be cared for at home. Some LTC facilities are affiliated with skilled nursing units. Staffing in LTC facilities depends on the level of care provided. If the residents are stable and need little nursing care, there may be one RN and several LPNs/LVNs, certified medication aides, and nursing assistants providing care. If the residents require more skilled care, more RNs are generally on staff. Therapies such as physical, occupational, and speech therapies may be available through the facility or through home health care.

home health care

many types of health or medical services provided to patients in their homes because they are confined to their homes by an illness or disability. Home health companies can be independent agencies, or they may be part of a hospital-based health-care system. They provide care in the form of skilled nursing visits with or without home health aide visits; physical, occupational, and speech therapy; medical social worker visits; infusion therapy; durable medical equipment; and hospice. The patient's primary care physician usually orders the home-care services, but a specialist may also oversee and order home care. Home health services must be medically necessary in order to be covered by Medicare and private insurance plans. Skilled services are those that require a license to be performed, and Medicare requires that a patient need skilled services in order to qualify for home health care. These skilled services may be a need for nursing, therapy, or social work. Skilled nursing visits include performing nursing assessment and evaluation, complicated dressing changes, and the administration of IV medications. Specially trained nursing assistants, or home health aides, provide nonskilled services. Examples of such services are assistance with bathing and grooming, housekeeping, transportation, and food preparation and delivery. Physical, occupational, and speech therapy services can be provided in the home by therapists who make home visits through a home health agency. The patient must be homebound to receive these services; otherwise, the patient could go to an outpatient therapy center for this type of care. Medical social worker visits can be ordered to assist patients and families with psychosocial support to help them deal with chronic, acute, or terminal illnesses. They also advise family caregivers, counsel patients, and help plan for patients' needs. They may arrange for community services such as Meals on Wheels, public transportation, medication assistance, and legal assistance. Home health care allows people to stay in their homes rather than being forced by medical needs to live in a health-care facility. Home visits for skilled care are a cost-effective way to provide limited care. An example of a patient needing this level of care is an elderly man whose wife died last year. He recently underwent abdominal surgery to repair a bowel perforation. His abdominal wound has not healed, and he requires dressing changes twice each day. A home health nurse comes each morning and evening to change the dressing, and a home health aide comes 2 days per week to help him take a sponge bath, changes his sheets weekly, and prepares a light lunch for him. The social worker has arranged for meals to be delivered through a neighborhood Meals on Wheels program. The patient's wound gradually heals, and he gains strength. He no longer needs home health assistance and goes to the senior center for his noon meal most days.

Hospice

medically directed nurse coordinator program providing a continuum of home and in pt care for the terminally I'll pt and family appropriate time for hospice care is when pt is no longer able to seek treatment to arrest or cure the disease and is expected to live 6 months or less. pt is treated with meds and other meds to relieve pain and remain comfortable. hospice services include managing pts pain and symptoms, lending emotional support to the pt and family, administering meds, providing medical supplies and equipment, , providing caregiver instructions and support, coordinating all health care services and providing grief support for surviving loved ones and friends. team consists of home health aids hospice dr, nurses, social workers, chaplain, clergy, trained volunteers, pts personal dr.

cardiac rehab

medically supervised program to help patients with cardiac disorders recover quickly and improve their overall physical, mental, and social functioning. The goal is to stabilize, slow, or even reverse the progression of cardiovascular disease, thereby reducing the risk of worsening heart disease, another cardiac event, or death. Cardiac rehabilitation programs include: • Counseling so that the patient can understand and manage the disease process • Exercise programs • Nutritional counseling • Risk factor modification • Vocational guidance • Instruction on physical limitations • Emotional support • Counseling on appropriate use of prescribed medications The cardiac rehabilitation health-care team consists of cardiologists (physicians who specialize in the diseases and treatments of the heart), nurses, physical/exercise therapists and assistants, and dietitians. Cardiac rehabilitation is provided through an outpatient setting of a hospital or at a freestanding facility.

duns theory of high level wellness

n 1959, H.L. Dunn developed a theory about achieving high-level wellness. In his theory, he uses not only a continuum of health and wellness, referred to as the Health Axis, but also a vertical axis to represent the person's environment. In this theory, there are four quadrants to describe a person's condition based on the influences of wellness or illness and a favorable or unfavorable environment. On the environmental axis of the grid, one end of the continuum is labeled "Very Unfavorable Environment," while the opposite end of the continuum is labeled "Very Favorable Environment." On the health axis, one end of the continuum is labeled "Peak Wellness," while the opposite end is labeled "Death." The four quadrants of the grid include: • Protected Poor Health: This occurs when the environment is favorable but health is not. • Poor Health: This occurs when both health and environment are not favorable. • Emergent High-Level Wellness: This occurs when the environment is not favorable, but health is favorable. • High-Level Wellness: This occurs when both the environment and health are favorable. If a person with an ongoing health condition such as severe congestive heart failure is in a favorable environment with family, caregivers, needed medications, appropriate diet, and regular physician visits, on Dunn's grid this person would be identified as having "protected poor health." It is easy to see that a person with an illness such as tuberculosis who is homeless would be considered to have "poor health" on this grid.

primary care nursing

one nurse is responsible for all aspects of nursing care for his or her assigned patients. This means that there is no UAP or CNA to take vital signs, no other nurse to call the physician or take orders, and no one else to bathe the patient or change the bed. In this type of nursing, the nurse carries a great deal of responsibility. A secondary nurse is assigned care for the patient when the primary nurse is off duty. The primary care nursing model is often used in intensive care units. An RN or LPN/LVN provides all aspects of nursing care to one or two critically ill patients. These nurses must be able to work quickly and efficiently in a crisis or under stress. In addition, they must be able to assess the patient carefully, making sure to note any small change in the patient's condition and correctly interpreting its significance. A disadvantage of this type of nursing delivery is that it works best when the number of patients assigned to the nurse is very limited, so it does not work well outside critical care areas.

ambulatory care clinics

operate much like a physician's office and provide the same type of services. Some may specialize in one type of care, such as urgent care or occupational health care. Ambulatory care clinics may provide a variety of health-care services under one roof. These services may include medical, dental, laboratory, x-ray, psychological, and/or pharmaceutical care.

rehabfacility

patient can receive intense physical, occupational, and speech therapy services. The rehabilitation facility may be part of a hospital, or it may be a freestanding facility. A physician specialist in physical medicine and rehabilitation oversees the patient's care during his or her stay. Other health-care team members who may participate in patient care include nurses, therapists, therapist assistants, nursing assistants, and technicians. As a rule of thumb, the patient must be capable of participating in at least 3 hours of therapy a day to be admitted to a rehabilitation facility. If the patient becomes ill or has other medical problems while in rehabilitation, he or she may be transferred back to an acute care hospital. An example of this level of care is a situation in which a female patient suffers a stroke and has weakness on the left side of her body. She is discharged from the hospital to a rehabilitation facility for 2 months of intensive therapy to regain as much strength and use as possible in her affected side. The therapy sessions are held every morning and afternoon. She is also expected to perform activities such as bathing and grooming with assistance. As her stay lengthens, she is expected to need less assistance. Another type of rehabilitation facility focuses on treating patients with chemical dependency and mental health issues. Some of these facilities provide medical care in the form of detoxification, or the removal of drugs and alcohol from the person's body, which generally takes several days. If the rehabilitation facility does not provide this type of care, patients have to be admitted to an acute care hospital for the detoxification process as it can lead to a medical emergency. After going through the detoxification process, patients can then be admitted to a rehabilitation facility designed to treat chemical dependency and mental health issues. Most generally, the physician who oversees the patient's care is a psychiatrist who specializes in treating mental or behavioral disorders. The health-care team in this type of rehabilitation setting consists of nurses, nursing assistants, clinical social workers who usually function as therapists or counselors, and psychologists. An example of the effective use of this level of care is the treatment of a young male patient who is addicted to the pain medication OxyContin®. He cannot really begin treatment for addiction until the drug is completely out of his body and the withdrawal symptoms are past. He goes through detoxification for the first few days after he stops taking the drug. The health-care staff monitors him closely for physical problems related to withdrawal, such as seizures, sweating, hallucinations, muscle pain, and nausea and vomiting. He then begins individual and group counseling sessions and group activities to deal with issues that led to his addiction.

physicians office

provides evaluation, assessment, treatment, simple diagnostic testing, and simple surgical treatment. The physician may specialize in one particular area of health care, seeing only patients with specific health conditions. The health-care team in a physician's office usually consists of the physician, a nurse or medical assistant, and medical office personnel. Administrative medical assistants are responsible for appointments, phone calls, collaboration with health insurance companies, billing, and other duties assigned by the physician. Most physicians participate in some type of group practice. The group may consist of physicians in the same specialty, or it may consist of different types of specialists that allow the patient to have a "one-stop shopping" opportunity. Physicians have developed group practices in order to cut administrative costs and receive assistance with health insurance contracting with the various insurance companies.

health department

public facilities that provide health-care services. These facilities are funded by county, city, state, and federal governments. Therefore, the cost of care at these facilities is lower than the cost of care at private clinics. In some cases, care is provided at no cost. The services provided are determined by the governing entity but may include immunizations, family planning, maternity education, well-baby clinics, adolescent health clinics, hearing and speech services, child developmental services, environmental health, and physical and occupational therapy. Health departments are also responsible for the tracking and treatment of certain communicable diseases, which are diseases that are transmitted through direct contact with an infected individual or indirect contact through a carrier. Some examples of communicable diseases that health departments treat and track include tuberculosis, sexually transmitted diseases, measles, mumps, rubella, hepatitis, flu, and certain viruses. An example of the use of this level of care is a teenage mother who is pregnant with her second child. She does not work because of the pregnancy and caring for her 18-month-old son. Her husband has been laid off from his construction job. She is seen at the health department for assistance with food and health care for herself and her child, through the Women, Infants, and Children (WIC) health program. She is provided with vouchers to buy healthy food, and her pregnancy is monitored for problems. Her son is provided with the appropriate immunizations and is monitored for normal growth and development.

Mental Health Facilities

services include intensive outpatient and partial day treatment programs. Intensive outpatient programs generally provide group counseling and therapy sessions for mental health and chemical dependency illnesses; these sessions generally last 2 to 3 hours per day, two to five times per week. Partial day treatment programs provide group and individual counseling and therapy sessions for mental health and chemical dependency illnesses, lasting approximately 7 to 8 hours per day during the week. An example of this level of care is a continuation of the client addicted to OxyContin whom we discussed earlier. After detoxification and inpatient treatment, the patient would be changed to partial day treatment. He comes to the mental health facility daily for 8 hours. As the client improves, he begins a job during the day. He then comes back to the facility 2 nights per week for group therapy sessions.

team nursing

uses a team consisting of nurses and certified nursing assistants (CNAs) or unlicensed assistive personnel (UAP) to provide care for a group of patients. This type of delivery system for nursing care is often used in the acute care hospital, rehabilitation setting, and LTC setting. In team nursing, each member of the team provides nursing care depending on his or her skills, education, and licensure. For example, a nursing care team in the acute care hospital might consist of an RN, an LPN, and a UAP or CNA, all of whom are responsible for the care of 10 patients. The RN might be responsible for assessing patients, administering some or all of the IV medications, maintaining the IV sites, communicating with physicians and obtaining orders, and ensuring that other team members have performed and documented care appropriately. The LPN/LVN might be responsible for administering medications to all of the patients as well as performing any treatments (for example, dressing changes), assessing the patient for any changes from baseline, evaluating pain levels and medicating appropriately, and providing patient teaching. The UAP or CNA might be responsible for helping each patient bathe and dress in a clean gown, changing sheets on the beds, assisting patients to the bathroom, and taking routine vital signs. The job duties are divided by the nursing team's level of knowledge and education. That is not to say that only nursing assistants should help a patient to the bathroom. The needs of the patients must be the first priority of everyone on the team. A disadvantage of team nursing is that, without excellent communication between team members, care may become fragmented