nursing week

Foundations of Gerontological & Community

Based NursingWeek I

Fiona Chatfield, RN, MSN, MBA, CCRNAdrianne Maltese, R.N., MN, GCNS-BCLos Angeles Valley CollegeE-mail: maltesam@lavc.edu

What is “Old”?

Young Old: 65-74 years old Middle Old: 75-84 years old Old Old: those over 85 years of age Centenarians: >40,000 persons in

US over the age of 100. Projected that by the year 2020, there will be > 3 million.

Factors influencing aging

Health (cognitive & functional capacity)

History (historic events/cohort group) Gender (affects various aspects of

aging)

Goals—to function at the highest level one is capable of.

U.S. National Health Goals’79, ’90, 2000

Healthy People 2010 objectives Increase quality & years of life for

Americans Eliminate/reduce health disparities Increase # health professionals of

racial/ethnic minorities Increase awareness & achieve access to

preventative services for all Improved surveillance and data systems in

health care

Community Based Nursing

Care for individuals, families, and groups where they work, or go to school or as they move through the health care system

Movement out of traditional, structured acute-care roles for nursing

↑ opportunities for nurses Employment opportunities and trends

Your Personal Experiences

Parents & Grandparents Extended Family Members Neighbors Community/Church/Religious Groups Friends Fellow Employees Caregiver

Scope of Practice

National Gerontological Nursing Associations (NGNA) scope & standards of care: Emphasizes the need for competent care of

older adults so that professional nurses (RN’s) will be prepared to “meet the special needs of the increasing numbers of older adults, particularly those over 85 years of age, minorities, and those with decreased financial and social resources” (ANA, 2001, p. 7)

Recognizes that the professional nurse may be ADN, BSN, MSN/MN, or Ph D. prepared.

Roles of the Gerontological Nurse

Generalist or Specialist Generalist

Various settings: home, hospital, nursing homes Performs: planning, delivery, evaluation of care

Specialist Advanced preparation (MN or MSN)

Gerontological nurse practitioner (GNP) Gerontological nursing clinical nurse

specialists

Food for thought…….

What are your thoughts about gerontological nursing? Feelings? Impressions?

What do you think would increase interest in gerontological nursing?

How does Geriatric nursing differ from Gerontological nursing?

Financing Health Care & Medicare

Soc. Security Act-1965Part A→ (free to all who are

eligible)

Part B→ optional (eligible must

pay a premium)

Part C →(Medicare Advantage Plan)’may include PPO’s & MCP’ s [HMO]

Part D→ Optional-eligible pay premium (added in 2006 to offset cost of Rx drugs)

Long Term Care Insurance

Hospital, SNF’s,Home Health, Hospice &

blood transfusions

MD visits, med equip. OP services, home health &

med supplies

Capitation imposed on MCP’s

has led to abuse/denial of care,

↓cost to elder; PPO – copays

Monthly premium & decuctible~$250.00/yr. max up to $2250/yr.

Optional (costly premiums)

What is Medi-gap insurance?

Purchased to offset Rx drug costs between $2250.00/yr. and $5100/yr.(coverage gap or donut hole)

Medicare pays 95% of cost after out of pocket reaches $3850.00/yr.

Medicaid –Social Security Act-1965

Provides financial assistance –pays for health care for poor, blind, disabled, & families with dependent children

Eligibility, service coverage varies from state to state.

States are required to cover hospital care (inpt/outpt), SNF, home health, family planning, MD visits, periodic screenings, tx. for eligible children.

Community Health approach

Primary Health Care Secondary Health Care Tertiary Health Care

Examples of Wellness Diagnoses

Ability to perform ADL’s Seeks out services when appropriate Manages stress effectively Maintains healthy lifestyle Plans and follows a healthful regimen Has a effective support network Able to cope appropriately Seeks health information Practices health maintenance

Legal Issues in Elder Care

Competence and Capacityability to make decisions regarding Finances medical/health decisions Understands consequences of

actions/choices Informed consent

Power of Attorney

Two types:

General POA

Durable POA

Appointee- known as the Attorney-in-fact

Power to make financial decisions& pay bills (no health care decisions)

Can make financial & health care decisions

(must be willing to uphold wishes on incapacitated person)

Guardians and Conservators

Guardianships & Conservatorships – Elder is declared “incompetent” or to

“lack capacity” (eg. Chronic mental illness, dementia, brain trauma)

Individuals or agencies Must be appointed by court/hearing Renewed yearly Powers decided by court- based on

extent of capacity of the elder

Elder Abuse /Neglect

Types of Abuse: Physical Psychological/emotional Sexual Financial/material Medical (unwanted tx/procedures or

withholding of tx) Neglect[withholds food,clothes,shelter,care

etc.] Abandonment by primary caregiver

Abuse & Neglect of elders

Most abuse occurs in the home of elder

Most abusers caregivers: spouses (58%)or adult children(23-30%)(Murray,2005)

84% white elders Incidences expected to increase Abuse is episodic & recurrent Multiple risk factors

Risk factors /characteristics of Elder Abuse victims

Frail elder -dependent on caregiver Female > 80 + years of age Lives alone or with abuser Confusion/cognitive impairment Incontinent episodes Chronic Illness Mental disabilities

Characteristics of Abuser

Middle aged male or adult child Caregiving spouse w/ history of previous

abuse/alcohol abuse Previous history of violence/substance

abuse/mental health problems Financially dependent on abused Feels overwhelmed by burden of care Feels frustrated and resentful History of abuse and being abused Refuses to allow visitor to see elder alone

When elder abuse is suspected

Nursing Interventions: Conduct assessment of elder Check for bruises (varying stages), wounds,

fractures, signs of punishment/restraints Check labs Malnutrition/dehydration Sudden behavioral changes in elder File mandatory report to “Adult Protective

Services” (within required timeframe)

Characteristics: Ageism & Elderspeak

Beliefs/myths/stereotypes of elders Prejudice through

attitudes & behaviors

Any discrimination

A form of ageism Singsong voice Speaks in childlike

fashion Use of “pet names”

eg. “honey” “dear”“momma” “grandma”Using “we” in

questions/statements when “you” is meant

Communicating with Elders

Communication is especially important to gerontological nurses

Gerontological nurses need to communicate effectively with older pts with a variety of physical and cognitive impairments

Communication is dynamic process including verbal and non-verbal signals. Nonverbal communication is thought to

make up ~80% of communication.

Communicating with Elders

Guide to Communication Ask how the patient would like to be addressed Do not yell or speak too loudly Try to be at eye level with the patient Try to minimize background noise as it can make

it difficult for the pt to hear Monitor the patient’s reaction Touch the patient if appropriate and acceptable Provide written instructions (use large

print/contrast paper) Keep it simple when interacting with cognitively

impaired, anxious or client in pain or pain

Communicating with Elders

Active listening Use open-ended statement to

encourage the patient to talk Avoid misunderstandings Do not be afraid to acknowledge

your own feelings Encourage reminiscing & life review What if a patient starts to cry?

Communication Barriers

Fear of one’s own aging Fear of showing emotion Feeling the need to write down every

detail Lack of knowledge of the patient’s

culture, goals and values Unresolved issues with aging relatives “professional distance” Being overworked, overscheduled, or

lacking proper time to communicate with older patients

Lewis Study Guide Case Study Question: Chapter 5 #21 (pg 26)

An 82 year old patient with multiple health problems is hospitalized with a hip fracture. What Medicare coverage will apply to

treatment of the fractured hip? What criteria must be met for the patient to

receive Medicare benefits for hospitalization?

The patient is transferred to a skilled nursing facility for rehabilitation. Will Medicare continue to cover the expense of the skilled facility?

Case Study cont’d

The patient is too frail to complete rehabilitation and it is D/C’d. Custodial care is indicated. If the patient is placed in a nursing home or taken home to be cared for, what Medicare coverage is available for expenses?

The patient is taken to a daughter’s home for custodial care. The daughter and son-in-law are both employed. What community-based service might be appropriate to allow the family members to continue employment?

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