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Ebersole and Hess Gerontological Nursing and Healthy Aging in Canada, 3rd Edition by veronique boscart
Chapter 03 Communicating with Older Adults
PN Case Study: Visual and Auditory Changes
Mrs. Nicholas is a participant in day programming at her local community centre. The nurse attends a once-weekly session where the focus is on health teaching with a small group of older persons. The nurse has observed through previous weeks that Mrs. Nicholas has begun sitting in the front row but has become progressively less engaged in the discussions during the sessions. The nurse has also recently noticed some disagreements Mrs. Nicholas and her peer group.
Match the following definitions regarding hearing impairment to the appropriate term:
A. Hearing loss Diminished quality of life, social isolation, suspicion/paranoia ____ B. Consequences of hearing loss
A setting within which concern regarding hearing loss is more significant, as the majority of clients experience hearing impairment ____ C. Hearing screening Usually involves external and middle-ear abnormalities that reduce transmission of sound to the middle ear ____ D. Long-term Care (LTC) A prevalent, persistent condition, and the most common sensory impairment in Canadians over 60 years of age.
E. Conductive hearing loss Hearing loss resulting from damage to any part of the inner ear, or neural pathways to the brain ____ F. Sensorineural hearing loss Recommended as part of routine primary care for older adults, yet rarely done ____
Answer Key:
A. Hearing loss Diminished quality of life, social isolation, suspicion/paranoia B B. Consequences of hearing loss
A setting within which concern regarding hearing loss is more significant, as the majority of clients experience hearing impairment D C. Hearing screening Usually involves external and middle-ear abnormalities that reduce transmission of sound to the middle ear E D. Long-term Care (LTC) A prevalent, persistent condition, and the most common sensory impairment in Canadians over 60 years of age. A E. Conductive hearing loss Hearing loss resulting from damage to any part of the inner ear, or neural pathways to the brain F F. Sensorineural hearing loss Recommended as part of routine primary care for older adults, yet rarely done C
Rationale:
Hearing loss is a prevalent, persistent condition in older Canadians, and the most common sensory impairment in Canadians over 60 years of age. Hearing loss increases after the age of 40. Quality of life and communication are diminished with hearing loss and is associated with many negative outcomes. Some of these include decreased function, miscommunication, social isolation, depression, safety risks, and reduced income and employment opportunities. Hearing impairment may cause an older person to become suspicious, distrustful, or display paranoid thoughts; inappropriate communication may lead to an erroneous diagnosis of cognitive impairment. Hearing impairment is underdiagnosed and undertreated in older adults. Screening impairment and appropriate treatment is considered an essential part of primary care for older adults, yet it is rarely done. Hearing loss tends to be overlooked as a geriatric syndrome, and is of particular concern in LTC homes, where the majority of residents are affected. Conductive hearing loss usually involves the external and middle-ear abnormalities that reduce transmission of sound to the middle ear, as seen in otosclerosis, infection, perforation of the eardrum, or fluid/cerumen accumulation. Sensorineural hearing loss results from damage to any part of the inner ear or neural pathways to the brain, as seen in presbycusis.
Question 1
Use an X for the nursing actions listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) for the client’s care at this time. Only one selection can be made for each nursing action.
Nursing Action Indicated Contraindicated Non-Essential Collaborate with occupational therapy Feed in an environment free of clutter/distraction Discuss with family removing fat and sodium restrictions from diet Request order for calorie supplementation with med pass Request consult for feeding tube placement Request order for megestrol Evaluate medications for drug- drug and drug-nutrient interactions
Answer Key
Question 1 Use an X for the nursing actions listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) for the client’s care at this time. Only one selection can be made for each nursing action.
Nursing Action Indicated Contraindicated Non-Essential Collaborate with occupational therapy
x
Feed in an environment free of clutter/distraction
x
Ask family to visit at mealtimes (^) x Request order for calorie supplementation with med pass
x
Request consult for feeding tube placement
x
Request order for megestrol (^) x Evaluate medications for drug- drug and drug-nutrient interactions
x
Rationale:
Collaboration with occupational therapy can be helpful for individuals experiencing difficulties with eating. This client is attempting to feed himself, so occupational therapy may be able to provide alternate ways to capitalize on his efforts. Additionally, he has lost 10 lbs (4.5 kg) in a month, demonstrating that being fed by others may not be as effective, especially if they are rushed and cannot sit with him for the period that it takes to consume nutrient dense meals.
Ensuring the environment is conducive to eating (remove objects such as urinals and bed pans; clear bedside tables) is helpful to minimize distractions.
Dispensing a small amount of calorically dense oral nutritional supplement (2 calories/mL) during the routine medication pass may have a greater effect on weight gain than a traditional supplement (1.06 calories/mL) with or between meals, so requesting this order is appropriate.
The interactions between nutrients and medicines may affect metabolism, absorption, digestion, or excretion of drugs. Many older adults take a variety of vitamin and herbal supplements. It is very important for the nurse to obtain an accurate assessment of all the over-the-counter therapies and drugs the patient may be taking. As the patient’s drug profile changes, the nurse must continue to screen for drug–drug or drug–nutrient interactions and consult with the provider, pharmacist or dietitian as needed.
b. The MORSE falls scale can be done upon discharge by the home care nurse to identify her falls risk at home. c. Mrs. Parsons’ medication history is an important component of falls risk assessment. d. Appropriate interventions include adding grab bars in tub/shower and near toilet, ensuring a handrail is installed on front porch steps, elimination of clutter, removal of the bedframe or using a low-profile mattress. e. Mrs. Parsons will not likely need further support with ADLs.
Answer Key
ANS: A, C, D
Rationale:
The intrinsic risk factors for Mrs. Parsons include advanced age and a history of previous falls and chronic conditions (arthritis); other intrinsic risk factors include gait and balance problems, poor vision, postural hypotension, and fear of falling. The extrinsic risk factors identified include lack of grab bars in bathroom and obstacles (clutter in bedroom); assessment for others include design of stairs (including handrails), dim lighting, slippery or uneven surfaces, psychoactive medications, and improper use of assistive devices. The MORSE falls scale is used in hospital and inpatient settings. The Heindrich II can be done prior to discharge, to screen for falls risk and would be more appropriate for this patient. A thorough assessment of multiple medications (polypharmacy) and or use of high-risk medications such as psychotropics, or medications affecting blood pressure, balance or cognition should be completed prior to discharge. The interventions identified are relevant to Mrs. Parsons’ specific situation, although a thorough review of potential interventions is included in Table 12.3. Mrs. Parsons will likely need further support with ADLs. She experienced challenges prior to the current hospitalization (which resulted from a fall) and is unlikely able to access the microwave above the stove for meals; she would benefit from a meal delivery program. To ensure her safety in this environment, she will require a plan for someone to “check in” daily and may also benefit from the services of a PSW.
Chapter 16 Pain and Comfort PN Case Study: Chronic Pain Ms. Laurent (she/her) is a 65-year-old with a history of rheumatoid arthritis, hypertension, gastroesophageal reflux disease, asthma, and type 2 diabetes. The nurse is completing a review of systems prior to the client’s quarterly visit with the rheumatologist. Ms. Laurent denies a history of smoking or illicit drug use. She states she has a glass of wine at night to help her sleep, reporting that she is unable to relax and spends most nights tossing and turning. When
questioned about her daytime activities, Ms. Laurent admitted that she no longer participates in activities sponsored by the local Senior Center. She just does not feel like going out and has no energy, especially in the mornings. Her blood pressure is 138/82 mm Hg, heart rate 86 beats per minute, respirations 16 breaths per minute, and temperature 97.6 °F (36.3°C). She is 5’6” (167. cm) tall and weighs 120 lbs (54 kg) with BMI 19.36 kg/m^2. She rates her daily pain as a 7 on a scale of 0 to 10. She can stand up using chair arms for support; her gait is slow, and she uses a quad cane. She is dressed in sweatpants and a stained, oversized t-shirt; her short hair is greasy and unbrushed. Ms. Laurent scores an 8 on the Geriatric Depression Scale (short form). Medications include methotrexate 25 mg once each week, etodolac 300 mg three times per day, venlafaxine ER 37.5 twice a day, metformin 500 mg twice a day, glipizide 5 mg twice a day, lisinopril/hydrochlorothiazide 10 mg/12.5 mg, beclomethasone dipropionate inhaled 2 puffs twice a day, and zafirlukast 20 mg twice a day. Question 1 Based on the client’s condition, the client’s priority need is to ______1________. In addition, interventions will need to be put in place to improve ___2_________ and ______2________. Options for 1 Options for 2 Control blood pressure Sleep Enhance nutrition Hygiene Manage pain Depressive symptoms Wash hair Blood pressure Stop drinking Body Mass Index
hypertension. He works full-time as an accountant. His wife remains at the bedside, working on crossword puzzles. She has her husband’s reading glasses in her purse. Mr. Antonov uses the call light asking for children to be removed from the room, as he cannot sleep with their noise. Upon arriving at the bedside, the nurse asks him to repeat his request. His eyes remain closed. The nurse gently asks again and palpates his shoulder; Mr. Antonov looks at the nurse, saying, “Huh? What?” before closing his eyes again. His blood pressure is 110/72 mm Hg, pulse is 68 beats per minute, respirations 14 breaths per minute and temperature 100°F (36.9°C). The abdominal dressing is intact with a dime sized area of serosanguinous drainage. Bowel sounds are hypoactive. Laboratory values include lipase of 100 IU/L, amylase of 130 IU/L, and urine positive for leukocyte esterase and nitrites. White blood cell count is 17.5 × 10^9 /L and neutrophils are 85%. Medications include cefazolin 500 mg IV every 8 hours and morphine 2. mg IV every 2 hours as needed for severe pain; hydrocodone/acetaminophen 5 mg/325 mg every 4 hours as needed for moderate pain and acetaminophen 650 mg every 4 hours as needed for mild pain. Question 1
Which intervention will the nurse contribute to the plan of care for this client? Select all that apply. a. Ensure the client wears glasses as appropriate b. Encourage family visitation. c. Provide relief from pain to less than a rating of 3 on a scale of 0 to 10. d. Encourage intake of food and fluids and maintain IV hydration as prescribed. e. Request an order for zolpidem 5 mg each night. f. Provide a calm environment with comfortable temperature and non-glaring light. g. Request an order for lorazepam 0.5 mg as needed three times per day.
Answer Key
Question 1
a, b, c, d, f Rationale :
The client may be developing delirium as evidenced by confusion, an elevated white blood cell count, and leukocyte esterase and nitrites in the urine. Prevention of delirium include:
- Sensory-perception enhancement (ensuring glasses, hearing aids, and listening amplifiers are used as appropriate)
- Mobility enhancement (ambulating at least twice a day if possible and safe to do so)
- Bedside presence of a family member whenever possible (to promote facial recognition and familiarity)
- Pain management (as pain can contribute to development or worsening of delirium)
- Nutritional and fluid repletion enhancement (appropriate nutrition and fluid status decreases the chance for dehydration, which can contribute to delirium)
- Sleep enhancement (as sleep deprivation can contribute to delirium)
- Management of environmental noise, light, and temperature (as a stimulating environment can contribute to delirium).
Contraindicated interventions include requesting medications such as zolpidem and lorazepam, which can further depress the central nervous system. Chapter 22 Neurological Disorders
PN Case Study: Parkinson’s Disease Mr. Newton, age 65, is seen by the home health nurse after a new diagnosis of Parkinson’s disease. He has a history of hypertension, type 2 diabetes, and chronic obstructive pulmonary disease. He has a 25-year history of smoking a pack of cigarettes a day and quit smoking 10 years ago. He is 6’2” (189 cm) tall and weighs 190 pounds (86 kg) with BMI 24.4 kg/m^2. On examination, Mr. Newton has resting tremor in both upper extremities. His voice is soft with occasional slurring; posture is stooped; and he takes short, shuffling steps that do not clear the floor. There is minimal arm movement with ambulation. He has difficulty initiating movement. His gait is unsteady, and he uses a quad cane for assist. He must use the arms of the chair to stand, and it takes several attempts before he succeeds in standing. His partner of 15 years is
Answer Key
Question 1
a, b, h Rationale :
Priority treatment is aimed at decreasing risks and enhancing safety; relieving clinical manifestations, increasing the ability to perform ADLs, and decreasing the risk for injury. Therefore, fall prevention, improvement of mobility (which contributes to fall prevention), and securing cords away from the walking paths (so the client doesn’t trip and fall) in the home are the priorities (a, b, and h).
The client’s hemoglobin and hematocrit are normal; the client is not anemic (c). Parkinson disease does not have a direct effect on immunity so enhanced immunity is not a priority (d). Drugs used to treat Parkinson disease cause constipation; therefore, intestinal mobility should not be decreased (e). The client’s weight and BMI are normal and healthy, and do not need to be increased (f). There is no evidence that the client has lung function concerns; additionally, he stopped smoking 10 years ago (g).
Chapter 23 Mental Health and Wellness in Later Life PN Case Study: Mental Health & Wellness in Later Life
Mr. Wellwood (he/him) is an 84-year-old man who is currently admitted to a medical unit after a diagnosis of pancreatitis. Mr. Wellwood is currently under investigation for unexplained abdominal pain and has been sleeping 2-4 hours per night while in hospital. Having provided nursing care over multiple shifts, the nurse has developed a strong therapeutic relationship with him. Through discussions with him, the nurse has learned that Mr. Wellwood has a military background and served overseas in active combat tours. He had been married, but he and his wife were divorced many years earlier after the death of their only child. He currently lives alone and participates in a weekly group at his local Community Centre. Until his hospital admission, he had been driving to run errands and shop for groceries. Mr. Wellwood is financially able to
hire a PSW to help with meal preparation, cleaning, and organizing his medications; they usually visit three times per week.
Question 1 Which of the following may suggest further investigation is required to determine a potential mental health diagnosis? (Select all that apply.)
a. Unexplained abdominal pain b. Poor sleep c. Current physical health challenges d. Death of his child e. Hiring a PSW
Answer Key: Question 1 A, B, C, D Rationale: Mr. Wellwood’s history and current status suggests further investigation may be required. Anxiety and PTSD may be potential diagnoses. At least 11% of older adults are diagnosed with anxiety each year. Although there are barriers to both reporting and recognizing anxiety, the nurse would assess for somatic symptoms (for example GI symptoms, headache, pain), sleep disturbances, as well as excessive worrying, difficulty concentrating, irritability and muscle tension. Risk factors for anxiety include poor physical health, high-stress life events (such as military experience and death of a child), low socioeconomic status, female gender, childhood abuse, other mental health diagnoses. PTSD has a lifelong prevalence of 9.4% among Canadian adults and may develop because of trauma long past, or more recent experiences. Mr. Wellwood’s experiences in war are a risk factor, and the presenting symptoms of sleep disturbances, somatic symptoms and anxiety are significant. Further investigation is required. Mr. Wellwood’s financial stability is not suggestive of a potential mental health disorder such as anxiety or PTSD. Chapter 24 Economic and Legal Issues
at lunch to provide care. Mrs. Chandler is 5’8” (173 cm) and weighs 135 lbs (61 kg) (BMI 20. kg/m^2 ). The nurse flicks a cockroach off the bedsheet, then examines the client. Her blood pressure is 134/88 mm Hg, heart rate is 86 beats per minute, respiratory rate is 14 breaths per minute, and her temperature is 96.2°F (36.4C) axillary; her oxygen saturation is 98% on room air. She has a stage 2 pressure injury on her coccyx measuring 4 mm x 5 mm x 2 mm; the base is pink, and the wound is surrounded by 3 mm to 4 mm of maceration. The house is in disrepair. There is a large hole in living room floor where it has rotted through; the hole is covered by a pool table. Mrs. Chandler’s bedroom is very small, with care supplies such as under pads, dressings, and bedding stacked in corners and against the walls. There is no TV or radio in the room. A Hoyer lift is in the hallway.
Answer Key Question 1: ANS: A, B, C, E, F Rationale: Neglect is most often passive mistreatment, such as an act of omission. Passive neglect is the failure to provide the goods and services such as food, medications, medical treatment, and personal care necessary for the well-being of the care recipient. Signs of neglect may include unhealthy living conditions, or the individual being malnourished or dehydrated, as well as fecal/urine smell, inappropriate clothing to the situation or weather, or insect infestation. A client who is bedridden requires frequent turning/repositioning and transfer to a chair in order to optimize health outcomes and prevent the development of pressure injury. The caregiver does come and check client at lunchtime to provide care, which is favorable, yet this still demonstrates that in between her leaving the home and returning, the client’s needs may not be met. Double padding the client for incontinence has also likely contributed to the stage 2 pressure injury and maceration. The presence of insects suggests a failure to provide a clean and safe living environment. Mrs. Chandler’s vital signs would not suggest neglect or present an immediate concern, although the nurse would need to complete a detailed health history and identify baseline vital signs. The presence of a pressure injury is an issue of physical safety, reflecting the distinct possibility that the client is not turned or moved often due to the caretaker’s work schedule. The presence of care supplies stacked in corners and against walls is another potential safety concern; with cockroaches on the bed, they may infest these supplies. This could also be an indication that there are not clear pathways in the room, contributing to falling hazards.
Question 2: Highlight the assessment findings that require immediate follow up by the nurse The nurse is conducting a home visit. Mrs. Chandler is 92 years old. She is bedridden, but occasionally is up in the Geri chair. She laughs and responds to simple questions appropriately. Her medical history includes hypertension, heart failure, and peripheral vascular disease; she had a cerebrovascular accident five years ago, and since then she has been fully dependent on others for activities of daily living. Mrs. Chandler can pick at food with fingers although she is usually fed by someone, as she has poor coordination in her upper extremities. She lives with her niece and caregiver, Ms. King, who has three children between the age of 7 and 16. The oldest child helps some by watching his great-aunt while his mother shops. Working full time, Ms. King double pads Mrs. Chandler for incontinence while at work and comes home at lunch to provide
care. Mrs. Chandler is 5’8” (173 cm) and weighs 135 lbs (61 kg) (BMI 20.52 kg/m^2 ). The nurse flicks a cockroach off the bedsheet, then examines the client. Her blood pressure is 134/88 mm Hg, heart rate is 86 beats per minute, respiratory rate is 14 breaths per minute, and her temperature is 96.2°F (36.4C) axillary; her oxygen saturation is 98% on room air. She has a stage 2 pressure injury on her coccyx measuring 4 mm x 5 mm x 2 mm; the base is pink, and the wound is surrounded by 3 mm to 4 mm of maceration. The house is in disrepair. There is a large hole in living room floor where it has rotted through; the hole is covered by a pool table. Mrs. Chandler’s bedroom is very small, with care supplies such as under pads, dressings, and bedding stacked in corners and against the wall. There is no TV or radio in the room. A Hoyer lift is in the hallway.
Rationale: Neglect is most often passive mistreatment, such as an act of omission. Passive neglect is the failure to provide the goods and services such as food, medications, medical treatment, and personal care necessary for the well-being of the care recipient. Signs of neglect may include unsanitary living conditions, or the individual being malnourished or dehydrated, as well as fecal/urine smell, inappropriate clothing to the situation or weather, or insect infestation. In this scenario, findings that require follow up include: o Occasionally up in the Geri chair, and bedroom is very small, with care supplies such as under pads, dressings and bedding stacked in corners and against the walls and there is no TV or radio in the room: A client left in bed in a very small room without TV or radio neglects to address the client’s need for stimuli and socialization. o Usually fed by someone due to poor coordination in upper extremities: Although the client’s BMI is within normal range, she is left alone for hours at a time with poor coordination in her upper extremities. It is uncertain if she can ensure her needs for nutrition or fluid are met in a timely fashion. o Ms. King double pads Mrs. Chandler for incontinence while at work and comes home at lunch to provide care: The caregiver does come and check client at lunchtime to provide care, which is favorable, yet this still demonstrates that in between her leaving the home and returning, the client’s needs may not be met. Double padding the client for incontinence has also likely contributed to the stage 2 pressure injury and maceration. o The nurse flicks a cockroach off the bedsheet and large hole in living room floor where it has rotted through; the hole is covered by a pool table: There is a cockroach on the client’s bedding, and a hole in the house flooring affording access of insects and possible other vermin. Both concerns are safety issues. o She has a stage 2 pressure injury on her coccyx measuring 4 mm x 5 mm x 2 mm; the base is pink, and the wound is surrounded by 3 mm to 4 mm of maceration: This is an issue of physical safety, reflecting the distinct possibility that the client is not turned or moved often due to the caretaker’s work schedule. o Care supplies such as under pads, dressings and bedding stacked in corners and against the walls: this is another potential safety concern; with cockroaches on the bed, they may infest these supplies. This could also be an indication that there are not clear pathways in the room, contributing to falling hazards.
Chapter 27 Comfort, Palliative Care, Death & Loss
Provide information relevant to the needs, and support that meets cultural and religious needs as well Listening
Chapter 28 Care Across the Continuum
PN Case Study: Care Across the Continuum
Mr. Addy (he/him) is a 68-year-old Indigenous male currently admitted to an acute care facility after experiencing complications from diabetes. Discharge planning is currently underway with the health care team. Mr. Addy has identified a goal of living independently, though he is open to having a roommate. He has a small home in the east end of the city, where there are local parks and gardens, community activities, and a convenient bus stop. It is anticipated that Mr. Addy will have adequate mobility but may require some support in terms of nutritional support and medication regimen. Financial burden is a concern for Mr. Addy.
Question 1: Which of the following statements regarding Mr. Addy’s situation are accurate****? (Select all that apply.)
a. Age-friendly communities are likely to be in urban, suburban, and rural areas.
b. Cohabitation would be an appropriate option to pursue for Mr. Addy.
c. Home care would provide the social support required by clients living independently at home. d. A retirement home is likely not the best option for Mr. Addy.
e. Discharge home is a period during which an older person may be vulnerable.
Answer Key
B, D, E
Rationale:
Age-friendly communities have eight key domains, including outdoor spaces and buildings, transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, and community support and health services. These are more likely to be found in urban or suburban areas, rather than rural areas. Cohabitation, while not formalized in Canada, may be an option for Mr. Addy. This type of
arrangement has been shown to have a positive impact on well-being, finances, health, social life, and daily satisfaction. Home care provides specific health services in the home, whereas programs such as Adult Day Services provides social supports such as meals and recreation in a supervised, safe setting. While a retirement home provides housing in addition to other services such as meals, medication assistance, and ADL supports, they often require that the individual pay for these services as they are not covered by provincial health care. This may not be an option for Mr. Addy, since he does not require such level of care and he has limited financial resources. Transitions in care require multidisciplinary communication and coordination, and older adults often experience care deficiencies when undergoing transitions. At particular risk include older persons who have multiple medical or mental health diagnoses, isolated persons, non-English speaking individuals, immigrants, and persons with low-income.
