Exam 3 Flashcards

Question

Assessment for Coping

Answer 1

- Risk factors of life transition, loss, and loss of social support - History of ability to cope with stress and life events - Assessment of cognitive function and/or impairment - Assessment of substance abuse and suicide risk

Answer 2

- Enhancing characteristics of hardiness, resilience, and resourcefulness - Enhancing functional status and independence - Promoting sense of control - Fostering social supports and relationships - Education regarding available resources

Answer 3

Attitudes & Beliefs - stigma - myth that it is normal Availability & Adequacy of Care - access - ability to pay Care Settings - place of treatment - who is providing care (staffing) Cultural & Ethnic Disparities - poverty - language - cultural understanding

Answer 4

NOT part of the normal aging process - Life events and stressors may contribute to development of anxiety disorders Associated with: - excessive healthcare use - decreased physical activity and functional status - substance abuse - decreased life satisfaction - increased mortality rates

Answer 5

- Difficult to diagnose in older adults - Denial - Coexisting medical conditions can mimic anxiety - Common side effect of certain drugs - Drug and alcohol withdrawal also can cause anxiety symptoms

Answer 6

Treatment choices depend on symptoms, specific anxiety diagnosis, comorbid medical conditions, and current medications Therapeutic relationship between patient and HCP is the foundation for any intervention

Answer 7

Antidepressants - SSRIs - First line Short acting benzodiazepines - Second line and short, bridge course Non-benzodiazepine anxiolytic agents

Answer 8

- Cognitive behavioral therapy (CBT) - Mindfulness-Based Stress Reduction (MBSR) - Meditation - Exercise (Yoga)

Answer 9

NOT a normal part of aging - MOST common mental health problem of late life - one in ten older adults visiting a physician suffers from depression - Depression and illness are likely to co-occur - r/t medical conditions - Medication SE - ACEI, antidysrhythmic, antibiotics...

Answer 10

- Major source of morbidity in older adults - Increased disability - Delayed recovery from illness and surgery - Excessive use of health services - Cognitive impairment - Decreased quality of life - Increased suicide and non-suicide related death

Answer 11

Multifactorial - Health and chronic conditions (box 28.14, p 357) - Gender (female) - Developmental needs - Socioeconomics - Environment - Personality - Losses - Functional decline - Medications (box 28.16, p 357)

Answer 12

- Comedic medical conditions strongly related to depression in older adults - More somatic complaints (physical symptoms) - Hypochondriasis (constant complaining and criticism) - Decreased energy and difficulties completing ADLs - Social withdrawal - Decreased libido - Preoccupation with death - Memory problems - *Strong association of depression with dementia - Risk factors for depression in older adults (box 28-16)

Answer 13

- geriatric depression scale (GDS), H&P, functional and cognitive assessment, medication review, lab analysis, comorbid conditions (box 28.17, p 358)

Answer 14

- If GDS is positive, need further assessment - Treatment should begin promptly - Combination of pharmacologic therapy and psychotherapy (CBT) and counseling (BEST) - Music, dance

Answer 15

SSRIs (fluoxetine, sertraline) SNRIs - second line (venlafaxine) - Tailored to specific patient needs - Trials of alternate medications and psychotherapy required in many patients - ECT therapy Avoided: tricyclics, older MAOIs (higher risk of falls)

Answer 16

Safe therapy for older adult patients at risk for harm due to suicidal ideation, psychotic depression, or severe malnutrition - Efficacy rates ranging from 60-80% depression

Answer 17

- Older adults account for 15% of population but 20% of suicide deaths - Higher than any other age group - White and Native American men have the HIGHEST suicide rate in older adult population - Older widowers MOST vulnerable - Up to 75% of older adults who die from suicide visited physician within one month of death (routine depression screening important for all older adults)

Answer 18

- ANY reference to ending life must be taken seriously - Establish trusting and respectful relationship - Behavioral cues (goodbyes, giving away possessions)

Answer 19

If suicide risk suspected, as direct questions - Have you ever thought about killing yourself? - How often have you had these thoughts? - Do you have a plan to carry it out/How would you do it? High risk patients need to be hospitalized Moderate and low risk treated as outpatients - adequate social support - no access to lethal means

Answer 20

Alcohol - Often a coping mechanism in old age to deal with loss, anxiety, depression, chronic illness - Most severe abuse seen in ages 60-80 Gender Issues - Late onset alcohol abuse associated with illness, retirement, loss of spouse - White men 4x more likely to abuse alcohol - Number and impact of older female drinkers expected to increase Drug effects - Prescription and OTC medications have many adverse effects when combined with alcohol Physiology - Age related changes in water and body fat cause higher blood alcohol levels - Liver and kidney function interferes with alcohol metabolism and excretion - Increased risk of GI bleeding

Answer 21

- Screening for alcohol and drug use | - Comorbid conditions may mask decline caused by alcohol

Answer 22

- Must address quality of life and adapt it to meet needs - Treatment focuses on cognitive and behavioral approaches - Screening for alcohol and drug abuse - Education and counseling about alcohol and prescription, OTC, and illicit drug use - Referral to specialist and community resources

Answer 23

- Life threatening emergency | - Detoxification should be done in inpatient setting

Answer 24

- Misuse of prescription and OTC medications - Polypharmacy effects exacerbated with alcohol use - Inappropriate prescribing and ineffective monitoring of controlled substances

Answer 25

MEDICAL EMERGENCY - Cognitive changes in older people often labeled as confusion by providers and frequently accepted as a normal part of aging - Delay in treatment contributes to negative outcomes with delirium - Associated with increased length of stay, morbidity and mortality, institutionalization, and comorbid illnesses - Significant distress for patient and family Assessment tool: CAM

Answer 26

- Occurs in older adults across the continuum of care - Among medical inpatients, delirium is present on admission to the hospital in 10-31% of older patients - During hospitalization, 11-42% of older adults develop delirium - Highest incidence is in ICUs and subacute settings - Prevalence of delirium in the community is low

Answer 27

- Older patients with NCDs are 3-5x more likely to develop delirium - Delirium superimposed on NCDs can accelerate the trajectory of cognitive decline and is associated with a high mortality

Answer 28

- Acute illness - Infections* - Medications - Invasive equipment - Metabolic disturbances - Dehydration* - box 29.2 - Alcohol or drug abuse - Sensory impairments - Unrelieved pain - Surgery - Hip fracture - Cognitive impairment (hx of dementia) - Age Early onset dementia (<60) is more related to genetic susceptibility (if their daily life is impaired, it's more likely dementia, not delirium)

Answer 29

Gradual onset with steady decline In elderly, often seen as a normal part of aging - Decline - Yes, "forgetfulness" - Dementia - No (represent serious pathological alterations) Any mental status change in older adult warrants a comprehensive assessment

Answer 30

IRREVERSIBLE state that progresses over years in decline of intellectual function Clinical features include at least one of the following: - Aphasia - Apraxia - Agnosia - Disturbances in executive functioning (attention, decision making, consciousness, memory, problem solving)

Answer 31

Most common form of dementia Age 30-60 (early onset) - less than 5% - Familial Alzheimer's disease (FAD) - genetic Age 60+ (late onset) - accounts for most cases - Not specifically genetic - Environmental factors, lifestyle, and genetic mutations 2/3 are women -> r/t "survivor bias" 6th leading cause of death and 3rd most expensive medical condition Increased number of ß-amyloid proteins (plaques) outside the neuron and accumulation of tau proteins (tangles) inside the neuron Starts where memories are stored - Most recent memories lost first d/t issues learning/retaining information Decrease the risks for neurodegenerative disorders (box 23.11)

Answer 32

NO symptoms - Biological/neurological changes started - Amyloid building may be detectable with: - > PET scan - > CSF analysis

Answer 33

Noticeable changes in memory and thinking - Can be measured - May not yet effect day-to-day life - Difficulty managing money issues - Increased forgetfulness - > Appointments - > Social engagements - > Lose train of thought - Decision making becomes overwhelming - Trouble finding way around - Impulsive - Irritability/aggression - Anxiety - Apathy

Answer 34

Multiple changes and deficits now present Other cognitive aspects: - word finding - vision/spatial issues - impaired reasoning/judgment At this stage, individuals may: - Require full-time assistance with ADLs - Lose awareness of experiences and surroundings - Have changes in physical abilities - > Walking, sitting, eating/swallowing - Have increased difficulty communicating - Become vulnerable to infections, especially pneumonia

Answer 35

Decline from previous level of functioning - Documented exam Onset was insidious - Without being specifically apparent Gradual regression in cognitive abilities - Beyond what is expected of age and education

Answer 36

More effective and improve quality of life Activities, therapies, exercise, sensory stim, reminiscence, environmental design, staffing, lighting, relaxation, distraction, non-confrontational approaches - Person-centered care - Foster abilities - Support limitations - Ensure safety - Enhance QOL - Prevent disability - Maintain function - Structured environment - Promote relationships

Answer 37

Aimed at slowing cognitive decline First Line: Cholinesterase Inhibitors (CIs) - Acetylcholine -> memory and thinking - Donepezil (Aricept) -> all stages - Galantamine (Razadyne) & Rivastigmine (Exelon) -> mild to moderate decline Other medications: - Memantine (Namenda) -> used in combination with CIs for learning and memory - Sleep aids - Antidepressants - Antipsychotics Communication box 29.14 Precipitating factors box 29.17

Answer 38

``` Anxiety Depression Hallucinations Delusions Aggression Screaming Restlessness Agitation Resistance to care ```

Answer 39

Stressors that may trigger symptoms - Fatigue - Change in environment, routine, caregiver - Misleading or inappropriate stimuli - Demands to perform beyond abilities - Pain, illness, depression Care - Structured to decrease stressors - Provide safe and predictable environment Outcomes - Improved sleep, less sedatives, better nutrition, socialization, decreased anxiety/agitation, care giver satisfaction

Answer 40

Behaviors have meaning and are attempted to communicate - Interaction between background and proximal factors Background - Cognitive changes, gender, ethnicity, culture, education, personality, responses to stress Proximal - physiologic needs - Food, pain relief, mood, physical environment (light, noises) Care - Manipulate proximal factors - Maximize strengths - Minimize limitations of background factors

Answer 41

Behavior and psychological symptoms of dementia (BPSD) - All behavior is meaningful and expression of need First rule out medical problems - > infection, dehydration, pain, fractures, impaction - > GI/GU problems cause much distress Consider psychosocial problems - > fear, discomfort, unfamiliar things, fatigue, depression, loss of control/autonomy, etc. - > May misinterpret stimuli

Answer 42

Wandering - Difficult problem to manage - Not well understood - Risk -> falls, elopement, injury, death Things to do: - Music, exercise, refreshments, social interaction - Camouflage doorways, enclosed areas for walking, electronic bracelets 60% will wander and become lost at some point wandering interventions/avoiding getting lost (box 29.25)

Answer 43

Can lead to distressing behaviors Nursing Actions: - Explain actions - Don't push - Positive feedback - Demonstration - Encourage self-care - box 29.23

Answer 44

Older adults with dementia are particularly at risk for weight loss and inadequate nutrition - Patients need to be fed - Choke - Refuse food Tube feeding at end-stage dementia - Not generally recommended (not shown to extend life or improve QOL) - Careful hand feeding -> as they want (box 29.27)

Answer 45

Magician - See the world through their eyes - Use tricks to augment behavior Detective - Investigate clues r/t behaviors Carpenter - Tools to individualize care Jester - Use humor - Spread joy

Answer 46

Rates of dementia: Rural - 5.1% Urban - 4.4% Lack of HCPs in rural areas - Neurologist and/or psychiatrists rarely in rural areas - Primary care may be the only option (often limited access) ``` Virtual/telehealth Home health services Rural community engagement and collaboration Transportation assistance Access to day services and respite care ```

Answer 47

Communication | - inability to communicate is dehumanizing (need)

Answer 48

- Precipitates healthy aging - Prolongs lifespan - Better response to medical interventions development of therapeutic relationships between nurse and older person

Answer 49

assume all older people can't hear, understand, or comprehend

Answer 50

- Simplistic vocabulary and grammar - Shortened sentences - Slowed speech - Elevated pitch and volume - Inappropriate terms of endearment - Speaking as if person is not there - Using familiar/informal communication without permission - Using the royal "we"

Answer 51

``` Tradition Modeling by others Unawareness Intent to control Insensitivity ```

Answer 52

Decreased self-esteem Depression, withdrawal Assumption of dependent behaviors

Answer 53

Give more time/Silence - must sort through any years of memories to answer Closed ended - to get specific answer - may feel put on the spot Open ended - allow for client elaboration - not sure what you are asking/want to please Proper body positioning Seek clarification Pay attention to non-verbal communication

Answer 54

Major communication issues related to neurological Reception - Anxiety - Hearing deficits - Changes in cognition Perception - Dementia - Delirium Articulation - Mechanical difficulties - Respiratory disease - Larynx disorders

Answer 55

aphasia - Intelligence not affected - Damage to brain (CVA or head trauma)

Answer 56

dysarthria - damage to neurological system - weakness of speech muscles Causes: - injury to brain - CVA, head injury, brain tumor, Parkinson's, MS Care: - collaboration with SLPs for speech therapy

Answer 57

- Have "slurred" or "mumbled" speech that can be hard to understand - Speak slowly - Talk too fast - Speak softly - Not be able to move tongue, lips, and jaw very well - Sound robotic or choppy

Answer 58

- Worst to lose (as described by older people) - Most common communication disorder - 3rd most common chronic condition in older adults - Men more affected - Underdiagnosed and undertreated - QOL diminished - > Decreased function - > Miscommunication - > Low self-esteem - > Depression - > Cognitive decline - Screening (usually not done) - Medicare doesn't pay for hearing aids - Medicare does pay for diagnostic hearing testing

Answer 59

Damage to inner ear or neural pathways - Presbycusis (type of sensorineural r/t aging) - > Most common - > Bilateral - Intolerant to loud noises - Difficulty in distinguishing between consonants (Z, S, Sh, F, P, K, T, G) - Raised voices often exacerbate the problem - High frequency sounds lost first - Difficulty filtering background noises (healthcare setting often noisy) Treatment: - Hearing aids - Cochlear implants

Answer 60

Vibrations can't get to the tympanic membrane or TM impaired Causes: - Infection, otosclerosis, perforated TM, fluid in middle ear - Cerumen impaction common cause Treatment: - Eliminate underlying cause - Review cerumen removal procedure, box 12.2

Answer 61

Abnormal sounds - Constant or intermittent - Worsens with age - Ringing, humming, buzzing, roaring, hissing, etc. Risk factors: - Presbycusis - Loud noises - Head and neck trauma - Tumors - Cerumen impaction - CV disease - Ototoxic meds - Meds SEs - ASA common

Answer 62

- 2/3 with impairment >65 - Among the top 10 causes of disability in the US - Lower quality of life and life expectancy - Low vision to to legal-blindness - > 20/40 to 20/200 - > how nurses screen vision? Leading causes: - Age-related macular degeneration - Cataract - Glaucoma - Diabetic retinopathy - Optic nerve atrophy

Answer 63

- Affects nearly all ADLs - Increase risk of falls - Increase risk of cognitive decline - Presbyopia - Age related vision changes - Lens loses elasticity - Difficulty focusing on near objects - Readers, bifocals

Answer 64

Leading cause of blindness Open and Closed angle - Angle controls outflow - Open angle most common and non-acute

Answer 65

Increase in intraocular pressure (IOP) imbalance between inflow and outflow of aqueous humor -> pressure increases -> vision impaired -> possible blindness if not treated

Answer 66

Initially none - Reduced peripheral vision - Tunnel vision - Blurred vision - Halos around lights - Eye or brow pain

Answer 67

- Vision exam - Tonometry (tests IOP) - Other advanced exams

Answer 68

Reduce IOP Surgery - Argon laser trabeculoplasty (ALT) - Opens outflow channels Medications - PO or eye drops (nursing considerations) - Lower IOP by increasing drainage of AH or reducing AH production - BETA BLOCKER drops are first line treatment

Answer 69

Prevention - Yearly eye exam for 65 and older - Report any eye s/sx immediately - African American at higher risk (yearly exams younger) Intervention - Eye provider follow up - Ongoing questions and vision testing - Care surrounding medication management

Answer 70

Oxidative damage to lens (protein and fat deposits) - By age 80, more than half have a cataract - Usually bilateral

Answer 71

- Clouding of lens - Absent red reflex or appear black - Appearance of halos around objects - Blurred vision - Yellow tint to vision - Sensitivity to glare

Answer 72

- Eye exam | - History

Answer 73

Surgical replacement of lens (plastic) - When vision 20/50 or worse - QOL or safety an issue - Outpatient - One eye at a time Nursing care peri-op - Prepare for changes in vision post-op - Avoid heavy lifting, straining, and bending - Eye drops - Eye shield

Answer 74

age-related macular degeneration

Answer 75

Leading cause of vision loss in 60 and over Dry (non-exudative) = 90% of cases Wet (exudative) = more severe

Answer 76

- UV light - Cigarette smoking - Light colored eyes

Answer 77

drusen deposits in retinal epithelium -> atrophy and degeneration of macular cells -> vision impairment

Answer 78

- Blurred and dark vision - Scotomas (blind spots) - Metamorphopsia (vision distortion) Diagnosis: - Drusen seen on opthalmascopy - Fundus photography - IV angiography and fluorescein

Answer 79

Promotion - After age 40 = dilated eye exam q2yr - After age 60 = eye exam yearly Supplements/diet - Vit C&E, beta-carotene, zinc - Dark green leafy vegetables - Smoking cessation - Management of HTN and DM - Sunglasses - Hats - Safety eye wear - Interventions to utilize remaining vision (vision won't return)

Answer 80

Use contrasting colors - Black and white - Reds and oranges easiest to see Assistive devices - Image magnification - Text-to-speech scanners - Tablets General - Closer to objects - Large type

Answer 81

- 10x stronger than verbal or emotional contact - Most neglected of the senses Response to touch: - Procedural vs. non-procedural touch - Boundaries of touch is often cultural - Don't assume one wants to be touched - A handshake (if appropriate) gives a lot of info (firm or soft, fast or hold on, warm or cold, sweaty or dry) Fear of touching: - Social status - Condescending touch (pat on the head, squeezing the toes)

Answer 82

- Desire for touch more powerful in old age - Cause of illness may be greatly influenced by quality of tactile support received - Higher death rates are more closely related to quality of human relationships than to degree of cleanliness, nutrition, physical disabilities on which we focus

Answer 83

Expectations - Cultural, biological, psychosocial, environmental factors influence sexual behavior of older adults - Factors affecting attitudes on intimacy and sexuality include family dynamics and upbringing, cultural and religious beliefs - Myths about sex and older women (box 33.1) Redefinitions in older adulthood - Sexuality in older person not about procreation - Emphasis shifts to - > companionship - > physical nearness - > intimate communication - Era in which a person was born influences attitudes about sexuality - > current older people often uncomfortable talking about sex/sexuality - > baby boomers more open

Answer 84

- Less likely to seek out health services - Less likely to identify themselves as LGBT to HCP - Often have differing or augmented healthcare needs - Older LGBT more likely to have kept their relationship hidden than younger people - National Gay and Lesbian Task Force Aging Initiative estimates about 3million Americans over 65 are LGBT, likely to double by 2030 - May face real or perceived discrimination in senior centers or long-term care facilities Assessment of need include use of strategic questions to obtain health history - "Do you have a romantic partner?" - "How do you identify with regard to your sexuality?" - Don't assume heterosexuality

Answer 85

- Menopause - Dyspareunia (painful intercourse) from vaginal dryness and thinning of the vaginal tissue Female dysfunction - Considered persistent impediment to person's normal pattern of sexual interest, response, or both - Influenced by culture, ethnicity, emotional state, age, previous sexual experiences, as well as changes in sexual response with normal aging Causes of female dysfunction - Physiologic changes (menopause/hormonal changes) - Water soluble lubricants, low-dose estrogens introduced into the vagina may also help restore tissues and lubrication Chronic illnesses and related treatments may bring many challenges to intimacy and sexual activities (table 33.2)

Answer 86

- Erectile dysfunction - Refractory period extended between episodes of intercourse Male dysfunction - Impotence (ED) - For most older men, caused by underlying medical diagnosis and/or the treatment - > Endocrine problems - > CV problems - > Depression - > Neurological problems - Phosphodiesterase inhibitors such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) (risk for drug interactions Chronic illnesses and related treatments may bring many challenges to intimacy and sexual activities (table 33.2)

Answer 87

Environmental factors - Lack of privacy - Absence of suitable partner - Family and staff attitudes - Dementia

Answer 88

On the rise HIV - Many symptoms mimic other disease conditions - Virus may be in late stages by time of diagnosis - Medicare in 2010 began covering HIV screening for high-risk individuals - All adults should have an HIV test at least once - Educational materials need to be developed for older adults

Answer 89

guide for discussion of sexuality in older adults Permission Limited Information Specific Suggestions Intensive Therapy box 33.8

Answer 90

- Educator - Facilitator - Consultant - Counselor - Advocate - Assessment of any medical conditions or medications associated with poor sexual health - Counseling for older adult to adapt to natural physiological changes or body-image alterations from surgical procedures

Answer 91

- Retirement no longer just a few years of rest from rigors of work before death - it is a developmental stage that may occupy 30 years - US retirement depends on the "three-legged stool" - > social security benefits - > savings - > private pension - Now more often a "one-legged stool"

Answer 92

- Retirement preparation programs are usually aimed at employees with high levels of education and occupational status, those with private pension coverage, and government employees - Retirement planning often lower priority - Retirement planning is advisable during early adulthood - Successful retirement depends on multiple factors (box 34.1)

Answer 93

Interventions that demonstrate effective care for an individual who has expressed a wish to retire - Asking about when they plan to retire - Assessing their ability to handle the stresses of retirement - Engaging them in conversation about their interest - Inquiring about the existence of any chronic illness - Scheduling a full physical exam

Answer 94

- Established in 1935 - during the Great Depression - Set up as an "age-entitlement" program under President Franklin D Roosevelt - Funded by payroll taxes - employees & employers contribute Amount of benefit calculation - Average salary during 35 of working years Current full benefit is 65-67y/o (have to wait to 70 to get the max amount) - May start at 62y/o at reduced benefit amount (25% reduction) May earn up to $18,960/yr from employment if under full retirement age - Will lose $1 of annual benefit for every $2 earned - Unlimited income if over full retirement age (up to max benefit) "Credits" 40 - box 30.2

Answer 95

Supplemental Security Income (SSI) - Provides for minimum level of economic support to persons 65+, blind or disabled regardless of earning power in early life or when capable of working - SSI either provides "total support" or supplements a low Social Security benefit (box 30.3) - May come from private retirement investments or employer pensions In the US, healthcare has always been a purchased service, not a right Federal government provides majority of care via its insurance plans - Medicare - an insurance plan for persons age 65, blind or totally disabled, including persons with ESRD - Railroad Medicare - Medicaid - TRICARE for lide - medigap for Medicare-eligible Vets - Veterans Administration - now need must be service related

Answer 96

- Specifically designed to provide almost universal health care for those who are eligible for Social Security - As soon as one is 65, they are automatically enrolled in Medicare Part A - > Medicare Parts B, C, D are selected on personal preference and availability - "Wellness visits" are available every 12 months after the initial exam (box 30.6) - CMS nurse

Answer 97

a hospital insurance plan covering: - acute care - short-term rehab in a skilled nursing facility or at home - most costs associated with hospice care box 30.7

Answer 98

Based in part on income reported to the IRS - Provides insurance coverage for many services provided on an outpatient basis, such as visits to providers (box 30.8) - Choice of PCP and referrals not usually necessary - Providers who "accept assignment" agree to charge only the "allowable" fee that Medicare determines - A provider that does not accept assignment may charge the patient 15% above the allowable charge

Answer 99

Referred to as Medicare advantage plans - Uses a prospective payment system to include traditional health maintenance organization and other managed plan - All traditional services covered by Medicare Parts A & B must be provided, and additional services, copays, and deductibles are predetermined - No care is obtained without a referral from the assigned PCP

Answer 100

The Medicare Modernization Act of 2003 established s prescription drug benefit for eligible recipients of Medicare (box 30.9) - It is an elective prescription drug plan with associated out-of-pocket premiums and co-payments - All persons with Medicare, except those in MAP-PD programs, are eligible to voluntarily purchase a PDP - > However, if one chooses to do so, the same rules and timing related to enrollment and incurring of penalties seen in Medicare B apply

Answer 101

- Because of potentially high deductibles and co-payments, people who are able to often purchase supplemental insurance plans - Medigap plans serve as a secondary insurance - Cover only deductibles and part of coinsurance amounts based on Medicare - > Approved amounts contracted with provider

Answer 102

Covers the cost of health services for low-income children, pregnant women, those who are permanently disabled, and persons age 65 and older who meet the States eligibility criteria - The majority of Medicaid funds are used to provide long-term nursing home care for older or disabled adults - "Spousal Impoverishment" limit of 1/2 of joint funds per spouse for use of eligibility determination and reimbursement

Answer 103

Medicaid - Primary payer for LTC services - There are large differences across states Medicare - Would not cover unless there was some skilled need - Many rules to being eligible for coverage Private LTC insurance - Relatively few people have purchased this insurance - Need to be aware of the exclusions in these policies before purchasing Out-of-pocket spending - Accounts for about 17% of national spending LTC

Answer 104

- In the US, the LTC system is complex, fragmented, isolated from other service providers, poorly funded, and confusing and difficult for the individual and the caregiver to negotiate - There is no comprehensive approach to care coordination and as a results, services and supports may not be provided in the most appropriate setting and by the most appropriate provider - Focus of acute care and LTC (box 32.2) - Goal of LTC (box 32.3)

Answer 105

- Women >80yrs - Widowed - Dependent in ADLs and IADLs - If 85y/o -> 1 in 2 chance of spending some time in NH

Answer 106

- Central focus - Interaction - Milieu ("feel" of the environment) - Environment - Individualized care - Staff - Safety

Answer 107

- MDS (minimum data set) - QAPI (quality assurance performance improvement) - Nursing Home Compare (5-star) - Advancing Excellence in America's Nursing Homes - INTERACT (interventions to reduce acute care transfers)

Answer 108

Program for All-Inclusive Care for the Elderly (PACE) - Medicaid and Medicare program that provides community services to people 55 or older who would otherwise need a nursing home level of care - Participants must meet the criteria for nursing home admission, prefer to remain in the community and be eligible for Medicare and Medicaid - National PACE Association (box 32.6) Adult Day Services (ADS) - Community-based group programs designed to provide social and some health services to adults who need supervised care in a safe setting during the day Continuing Care Retirement Communities (CCRCs) - Provide full range of residential options, from single family homes to skilled nursing facilities (SNFs) all in one location Residential care/Assisted living (RC/AL) - Provides housing and services to older adults in the US - Many older adults would move to an assisted living community if they could no longer care for themselves - Not covered by Medicare Assisted living (AL) - Popular type of RC/AL - Profile of a resident living in assisted living (box 32.7) - With the growing numbers of older adults with dementia residing in AL, many are establishing dementia-specific units Less disruptive if you age in place Chronic care is paid by medicaid

Answer 109

Delivery of around the clock care for those needing specialized care Characteristics: - Often includes up to two levels of care: skilled nursing care (subacute) and chronic care (long term, custodial) - Approximately 16,000 certified nursing homes in the US 1.7million beds - The majority of nursing homes are for-profit organizations Subacute care (short term) - More intensive and more costly - Most frequent site of post-acute care - Length of stay usually no more than 1-3 months ``` Chronic care (long term) - May not need intensive care, but still need ongoing 24hr care ```

Answer 110

- More RN direct-care time per resident in nursing facilities is associated with few pressure ulcers, fewer hospitalizations, fewer UTIs, less weight loss, fewer catheterizations, and less deterioration in the ability to perform ADLs - Nurses plat a key role in improving quality of care in nursing homes through EBP and leadership in quality improvement initiatives - The need for expert nursing is the most essential service provided Nursing Assistants - Provide the majority of direct care in nursing homes and significantly contribute to the quality of life for residents

Answer 111

- Residents in LTC facilities have rights under both federal and state law (box 32.11 - on exam) - LTC Osbudsman Program is a nationwide effort to support the rights of both the residents and the facilities - Each facility is required to post the name and contact information of the ombudsman assigned to the facility

Answer 112

- Providing a seamless continuum of care through improved coordination of acute care, post-acute care, and long-term care services and better management of transitions between care settings are essential in health care today to address both cost and quality issues - Interventions to Reduce Acute Care Transfers (INTERACT) is an exemplary program for reducing frequency of transfers to the acute hospital from nursing homes

Answer 113

- The ultimate vision of culture change is to improve the lives of residents and staff by centering facilities' philosophies, organizational structures, environmental design, and care around practices that support resident's needs and preferences - Institution-centered vs person-centered culture (box 32.14) - Principles of culture change (box 32.15) - Nursing home culture change competencies for nurses (box 32.16)

Answer 114

Self-determination (autonomy) is documented or expressed through what we refer to as informed consent, and in most circumstances is implied when a person accepts or cooperates with care - More complex consent is needed under certain circumstances (box 31.1) - Informed consent is only possible with the assumption that adults have decision-making capacity (a person can understand a problem, the risks and benefits of a decision, the alternative options, and the consequences of the decision)

Answer 115

Power of Attorney - Legally appointed to act on behalf of another in ways specifically indicated in a legal document - DPOA-HC -> Durable POA for health care continues after person can no longer speak for themselves Healthcare Proxy - Authority to act on a person's behalf when he or she has lost the capacity to male decisions and has not documented what they want (box 31.4 - hierarchy of appointments) Guardians & Conservators - Individual, agencies, or corporations appointed to take care, custody, and control of an incapacitated person and assure needs are met (box 31.6) What is the nurses responsibility? - Dealing with potential questions of the right to decision-making (box 31.15) - Do not attempt to provide legal advice, but instead refer to an elder law attorney

Answer 116

- Time for oneself - Keeping person safe - Balancing other responsibilities - Physically moving the person - Managing medical/medication regimens - Recreation Goals and best nursing practice - Education - Support - Resources - Coaching - Following up

Answer 117

- Physical abuse - Psychological abuse - Medical abuse - Financial abuse - Confinement - Sexual abuse Factors affecting identification of abuse (box 31.11) Cultural variation abuse/neglect (box 31.12)

Answer 118

- Complex phenomenon - All socioeconomic, racial, and ethnic groups - Can be intentional, accidental, episodic, or recurrent - Elder abuse is reportable by law Most abuse... - Occurs in home - Spouses or adult children - Majority of documented cases are white elders (84%)

Answer 119

- Women - Single - Cognitive impairment/dementia - Dependent on caregiver - Incontinent - Frail or mental disability - Previous abuser of the caregiver - Institutional setting

Answer 120

- Posttraumatic syndrome and lowered self-efficacy, even after the move away from abusive situation, may never be resolved - Those subjected to even minimal abuse have been found to have a 300% higher risk for death - Older adults who have been victims of violence have more health problems, including bone or joint problems, digestive problems, depression or anxiety, chronic pain, hypertension, and CV disease

Answer 121

Wrap around bruises (box 31.16) - Accidental bruises don't form a wrapped appearance - A bruise that wraps the wrist, arms, neck, or ankle may indicate force - Look for thumb pad on one side and finger pads on the other Linear bruising - Accidental bruising doesn't follow a linear pattern - Striking with an object can cause linear bruising - May be seen on back, buttocks, thighs, or arms

Answer 122

Evidence collection - Observe for obvious bruises or body marks - Observe and ask about medications - Look for sign of restraints - Note for body odor, dirty clothing or body, or other signs of neglect - Observe for pressure ulcers, dehydration, or malnutrition - Photograph injuries and general conditions (follow facility policy) Prevent abuse from continuing - Licensed nurses are considered mandatory reporters (required to report suspicions of elder abuse to Adult Protective Services) - Reasonable belief that a vulnerable person has, is, or likely to be abused, neglected or exploited

Answer 123

- In most states and US jurisdictions, licensed nurses are "mandatory reporters" and are required to report suspicions of abuse to the authorities - In each state, ombudsman are either volunteers or paid staff members who are responsible for active as advocates for vulnerable residents in institutions

Answer 124

Gerontological nurses should be alert to potential mistreatment of vulnerable elders and take steps to prevent the occurrence of abuse or neglect - Educate professionals and public - Support systems and groups - Stress management - Care resources - Counseling and caregiver self-care - Respite care and home health - Resources for meals and transportation

Answer 125

A means of financial or maternal exploitation - Undue influence may occur in an insidious way if the perpetrator isolates the victim from family and friends - If a person provides false affection and even marriage to a lonely person for the purpose of defrauding him or her of assets - Signs (box 31.13)

Answer 126

Results from failure of action by caregiver or through one's own behavior choices Neglect by caregiver - Requires a socially (formal/informal) recognized role and responsibility of one to provide care to a vulnerable other (box 31.14) Self-Neglect - People fail to meet their own basic needs in the manner in which the average person would in similar circumstances

Answer 127

An advocate is one who maintains or promotes a cause; defends, pleads, or acts on behalf of another; and fights for someone who cannot fight for themself Nurse advocates function in various arenas: - With their own discipline and other disciplines within their own agencies - With other agencies, physicians, and families - With neighbors and community representatives - With professional organizations, legislators, and the courts

Answer 128

Religious beliefs and church participation are often avenues of spiritual expression, but are not necessarily interchangeable ``` Religion = organized social institution Spirituality = broader concept that embraces one's values/belief system ```

Answer 129

Individuals experiencing events or conditions that affect ability to participate in spiritual rituals Diagnosis and treatment of a life-threatening, chronic, or terminal illness Expressions of interpersonal or emotional suffering, loss of hope, lack of meaning, need to find meaning in suffering - Does your religion/spirituality provide comfort or stress? - Do you have religious or spiritual beliefs that might conflict with health care or affect health care decisions? - Do you belong to a supportive congregation or faith community? - Do you have any practices or rituals that help you express your spiritual or religious beliefs? - Do you have spiritual needs you would like someone to address? - How can we help you with your spiritual needs or concerns?

Answer 130

- Promote physical comfort - Provide psychosocial comfort - Provide spiritual comfort Personal reflection - What do I believe in? - How do I find purpose and meaning in my life? - How do I take care of my physical, emotional, and spiritual needs?

Answer 131

- Feel warmth of the sun - Share experiences children are having - See crystal blue of sky - Enjoy garden or fresh flowers - Savor richness of black coffee - Feel tartness of grapefruit to wake up tastebuds - Listen to symphony - Watch activities of animal in tree outside - Benefit from each social encounter - Write messages to grandchildren/family - Study favorite painting - Build highlights into each day (meals, visits, religious reading) - Keep journal - Write letters - Make tape recording of life story - Have hope objects or symbols nearby - Share hope stories - Focus on abilities, strengths, past accomplishments - Encourage decision making about daily activities to foster sense of control - Extend care and love to others - Appreciate expressions of caring concern - Renew loving relationships

Answer 132

One's tangible and intangible assets transferred to another - Purpose of legacies is to supersede death - Older people must be encouraged to identify that which they would like to leave and who they wish recipients to be Autobiographies and life histories - Creating life history - Creating self through journaling Collective legacies - Generational accomplishments Legacies expressed through others - Mentorship - Organ donation Living legacies - donate body to science - Transcend death Property and assets - plan estates Knowledge - we build on thoughts and works of other Personal possessions - tender experiences that provides memories and meaning ``` Examples of legacies Oral histories Recipes Autobiographies Shared memories Taught skills Works of art, music Publications Endowments Objects of significance Written histories Tangible or intangible assets Personal characteristics such as courage or integrity Bestowed talents Traditions and myths perpetuated Philanthropical causes Progeny children and grandchildren ```

Answer 133

Loss, dying, and death are universal, incontestable events of the human experience - Loss of any kind has the potential to trigger grief and mourning - In later life one loss and its accompanying grief is often superimposed on others

Answer 134

In the Loss Response Model, grievers are viewed as part of a system that is striving to maintain equilibrium or stability - Person/Family/Grievers are a system - Loss creates chaos and disequilibrium - System must restore equilibrium Step 1: - Make sense of the loss - Search for meaning (why did this happen to me/us?) - Why wasn't it me? Step 2: - Integration and acceptance of the loss - Emotions stabilized or channeled - Others step in ready to assume roles of one lost Step 3: - System redefines itself - Reframing memories - Things may be different, but that is accepted

Answer 135

1. Denial - Shock (will wear off eventually) 2. Anger 3. Bargaining - Guilt 4. Depression 5. Acceptance - May be in any order - May repeat or happen simultaneously - Multiple stages may be experienced at once

Answer 136

anticipatory grief

Answer 137

acute grief

Answer 138

shadow grief

Answer 139

complicated grief

Answer 140

disenfranchised grief

Answer 141

Factors affecting the ability to cope with loss and grief (box 35.2) - Physical - Emotional - Social Identifying those with better coping skills (box 35.3) "Good Copers" acknowledge the loss and try to make sense of it Talking with people experiencing grief: - "I know how you feel" - "Your loved one is not sick anymore/is in a better place" - Invalidating feelings, making it about you

Answer 142

- Helping grievers move through the impact of loss to the reestablishment of new memories (box 35.6) - Impact and functional disruption - Searching for meaning, engaging emotions, and informing others - Adaptation - Memories reframed and the return to equilibrium and a new steady state

Answer 143

One of the most difficult life losses (second to loss of child) Spousal bereavement - greater in women than men (??) - Men tend to remarry sooner and more often than women - > loneliness, need to be cared for - > high suicide risk on widowers - 73% women over 85 widowed - 35% men over 85 widowed Whole person effects - physical, psychological, social, practical, and economic - Adjusting to loss 2-4 years - Support - Offer self - Caring - Nursing interventions - Assessment of grief stages and progress - MI and stroke risk increase in month after partner loss - Mental health - Suicide risk - Grief

Answer 144

- Nurses are on the front lines during loss and death - Must be able to respond properly to loss, dying, death, and grief - Patient-centered care during death/dying - Care behaviors should be exhibited (table 35.14) - S/S in terminal phase of dying (table 35.1) - A good death (box 35.9)

Answer 145

1. Care: - Free from pain - ATC (all types), listening, constant and ongoing support 2. Control: - Collaboration with patient (dignity) 3. Composure: - Moments of relief 4. Communication: - Closed awareness, suspected awareness, mutual pretense, and open awareness - Verbal, physical, tactile, sight - Information, decisions, relaying to others 5. Continuity: - Preserving as normal a life as possible while dying 6. Closure: - "resolution" of end of life (very individualized)

Answer 146

Spirituality - The spiritual dimension of persons who are dying deals with the transcendental or existential relationship between the dying person and another - between the person and their god or the person and significant others Hope - As death approaches, the hope may be for a good death, one that is symptom free Promoting equilibrium for the family - Nursing interventions that promote health at the time of loss include actions that empower the family to cope with the death, in a manner consistent with their traditions

Answer 147

is an approach to care which improves the quality of life of patients and their families facing life-threatening illness, through prevention, assessment, and treatment of pain and other physical, psychological, and spiritual problems

Answer 148

- "Expectation" of 6 or less months of life - Comfort - Dignity - Support the caregiver

Answer 149

- keep them informed - ask how they are doing and offer support - put their arm around them when they cried - brought them food - knew their name - cried with them - brought them a bed and encouraged - told me to hold his hand - got the chaplain for me - let me take care of my husband

Answer 150

The Silver Hour model focuses exclusively on the care given between the time that death is "first recognized" as an imminent possibility and until the patient leaves the site of death for burial Three phases of The Silver Hours 1. Dying - recognition that death is immanent - goals - ensure patient and family understands that death will occur - allow family as much access to dying patient as possible - promote shared decision making - transition from life-saving care to comfort care (this is a late time to start) 2. Death - declaration of death (brain or bodily death) - goals - available for support - facilitate grieving - follow wishes r/t death rituals - allow family to say goodbye 3. Dead - the body released to the next care provider (funeral home, morgue, etc.) - goals - discharge procedures - maintenance of family/patient wishes - make sure family knows how to contact funeral home/morgue - walk family to elevator, door, car, etc. - need for info and support after death is very important - what questions might a family ask the day after death?

Answer 151

- Physician assisted suicide illegal in most states - Sedation for/treatment of symptoms is appropriate and managed by nurses Palliative sedation - Giving sedation and pain medication - Give as much as needed (even if it does speed death) - Death is not the goal -- comfort is the goal

Answer 152

- Those without family support during the dying process - "No one dies alone" campaign (1986) - Seek out an opportunity to be with someone when they die

Answer 153

(top to bottom) 1. Biological & Physiological Integrity - to obtain relief from physical symptoms - to conserve energy - to be free from pain 2. Safety & Security - to be given the opportunity to voice hidden fears - to trust those who care for him or her - to feel that they are being told the truth - to be secure 3. Belonging & Attachment - to talk - to be listened to with understanding - to be loved and to share love - to be with a caring person when dying 4. Self-Esteem & Self-Efficacy - to maintain respect in the face of increasing weakness - to maintain independence - to feel like a normal person, a part of life right to the end - to preserve personal identity 5. Self-Actualization & Transcendence - to share and come to terms with the unavoidable future - to perceive meaning in death

Exam 3 Flashcards

(182 cards)