Foundations of Gerontological & Community Based Nursing Week I

1. Foundations of Gerontological & Community Based NursingWeek I Fiona Chatfield, RN, MSN, MBA, CCRN Adrianne Maltese, R.N., MN, GCNS-BC Los Angeles Valley College E-mail: maltesam@lavc.edu

2. 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.

3. 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.

4. U.S. National Health Goals’79, ’90, 2000 Healthy People 2010objectives • 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

5. 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

6. Your Personal Experiences • Parents & Grandparents • Extended Family Members • Neighbors • Community/Church/Religious Groups • Friends • Fellow Employees • Caregiver

7. 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.

8. 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

9. 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?

10. Soc. Security Act-1965 Part 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) Financing Health Care & Medicare

11. 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.

12. 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.

13. Community Health approach • Primary Health Care • Secondary Health Care • Tertiary Health Care

14. 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

15. Legal Issues in Elder Care • Competence and Capacity ability to make decisions regarding • Finances • medical/health decisions • Understands consequences of actions/choices • Informed consent

16. 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) Power of Attorney

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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 Characteristics: Ageism & Elderspeak

24. 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.

25. 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

26. 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?

27. 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

28. 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?

29. 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?