Analysis of Geriatric Care Needs

1. Analysis of Geriatric Care Needs Lorinda K Greer Ferris State University Nurs 314 Gerontological Nursing

2. Analysis of Geriatric Care Needs

3. Introduction • Eileen is 86 years old, widowed and lives independently in her older 2-story home • History: osteoarthritis, hypertension, CHF, GERD, and bilateral hip replacements • Medications: Vicodin for pain, Coreg for her CHF, lisinipril for her HTN, and prevacid for her GERD.

4. Introduction Continued • Able to care for self, do own laundry and cook meals • Family assists with heavy cleaning and home repairs • Because she has never driven, she depends on her family to take her shopping and to her doctor’s appointments. • Uses wheeled-walker for ambulation

5. Introduction Continued • Eileen is on a fixed income, receiving Social Security and Medicare benefits • Family has been encouraging her to move from her large, older home into a smaller apartment or retirement community • Eileen is determined to stay in her home and does not want to move

6. Assessment : Tools • Fulmer SPICES • Numeric rating scale (NRS) • Geriatric Depression Scale • Lawton’s Instrumental Activities of Daily Living

7. Assessment: fulme’r SPICES • S = Sleep disorders • P= Problems with eating or feeding • I= Incontince • C= Confusion • E= Evidence of falls • S= Skin Problems

8. Assessment: Fulmer’s SPICES • “SPICES” is an “effective instrument for obtaining the information necessary to prevent health alterations in the older adult patient,” (Wallace & Fulmer, 2007). • Eileen denies problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown. • However, sleeping has always been an issue for her, especially falling asleep

9. Assessment: Fulmer’s SPICES • Difficulty falling asleep • Usually is up late due to restlessness • Falls asleep well after three o’clock in the morning • Wakes up after ten in the morning. • Naps regularly in the afternoon for two to three hours a day • Tries to go to bed early, but has trouble getting to sleep. • Reports the Vicodin for OA helps her sleep better at night

10. Assessment: Numeric Rating Scale • Pain is assessed by rating pain on a 0 to 10 scale with 0 meaning no pain and 10 the worse pain ever (Flaherty, 2008) • Further interpreted as 1 to 3 being mild pain, 4 to 6 representing moderate pain, and 7 to 10 signifying severe pain (Flaherty, 2008) • Eileen rated her pain as a “5”, meaning moderate pain

11. Assessment: Geriatric Depression Scale • The GDS is a short 15 question yes/no questionnaire used to assess mood and can provide insight as to whether a more in depth assessment is necessary (Greenberg, 2007) • Eileen scored 2 out of 15, preferring to stay at home, rather than going out and doing new things and not feeling full of energy • If she answered honestly, her score was less than 5, therefore no indication for depression

12. Assessment: Lawton’s Instrumental Activities of Daily Living Scale • Lawton’s IADL scale “assesses a person's ability to perform tasks such as using a telephone, doing laundry, and handling finances,” (Graf, 2008) • She scored “0” for shopping and driving, because she does not drive and has not for many years • She scored a “1” for using the telephone, food preparation, cleaning, laundry, medications, and finances • Total score= 6 out of 8

13. Cultural Considerations • European American values include, “individualism, autonomy, future orientation, and mastery of the environment (Omizo, Kim, & Abel, 2008) • Eileen is of European decent and is able to trace her ancestry to the Mayflower • She is independent and has an unwavering commitment to stay in her home. • She does not regularly attend church, but has a strong spiritual life • Reading her Bible and praying every day.

14. Biological Theories of aging:the Gene/Biological Clock Theory • The Gene/Biological Clock Theory suggests genetic predisposition affects the aging process (Grossman &Lange, 2006). • Eileen’s mother suffered from high blood pressure and arthritis which may be contributing factors to her CHF and OA.

15. Biological Theories of aging: The Free Radical Theory • The Free Radical Theory is characterized as, “end products accelerate oxidative metabolism, and react with proteins, lipids, and ribonucleic acid (RNA) to cause cell damage leading to diseases such as diabetes and arthritis, gene modulation, lipid peroxidation, and accelerated aging,” (Grossman & Lange, 2006). • Based on this theory, Eileen’s heart failure and osteoarthritis may be caused by oxidative damage to her cells.

16. Nursing diagnoses • Chronic pain related to osteoarthritis, as evidenced by Eileen’s pain rating of “5” on the numeric rating scale, sleep difficulties, and facial expressions (Cox et al., 1993). • Sleep pattern disturbance related to chronic pain and restlessness, as evidenced by Eileen’s verbal complaints of difficulty falling to sleep (Cox et al., 1993). • Impaired physical mobility related to pain and musculoskeletal impairment from her OA, as evidenced by decreased muscle strength (Cox et al., 1993).

17. Planning • Eileen will maintain a tolerable level of pain by April 20. • She will verbalize a pain rating less than “3” according to the NRS by April 25. • Eileen to report falling asleep before midnight by April 30. • She will express decreased number of complaints of being unable to fall asleep by May 15. • Exhibiting the ability to perform active range of motion and muscle strengthening exercises by May 20. • She will also show improved muscle strength and endurance while ambulating by June 1.

18. IMPLEMENTATION • Interventions addressing her chronic pain should be the first priority. • “Pain will compromise one’s quality of health, it will affect both mental and physical functioning,” (Ebersole, Hess, Touhy, Jett & Luggen, 2008, p. 282). • Eileen will explore what activities exacerbate her pain and what times of day her pain levels increase. • Based on this information, a pain medication schedule will be developed and adhered to for optimal pain control. • To better understand her pain, she will learn the concepts of rating pain, utilizing the numeric rating scale. • Eileen will learn alternative pain therapies, including heat therapy, distraction and relaxation techniques. • Because she is active spiritually, prayer and meditation could be incorporated to help alleviate pain. • Distraction through music and rhythmic breathing may be useful by allowing one’s mind to concentrate on something other than pain, including pain from osteoarthritis (Ebersole, Hess, Toughy, Jett & Luggen, 2008, p. 289).

19. Implementation Continued • Relaxation techniques learned for pain management such as meditation, rhythmic breathing, music and prayer will also be implemented prior to bedtime to help Eileen fall asleep. • She will also monitor her pain level using the NRS prior to bedtime and take prescribed pain medication. • Eileen will also demonstrate sleep preparation activities such as eating a high carbohydrate snack, having a warm drink, and creating a calm sleep environment. • According to the Hartford Institute, “every effort must be made to create a good sleep environment for older adults,” (Fulmer, 2007).

20. Implementation Continued • Interventions regarding impaired mobility have also been added to Eileen’s plan of care. • She will learn active range of motion exercises to increase muscle tone. • Regular exercise promotes joint flexibility, improves function and coordination, increases energy, and reduces pain (Ebersole, Hess, Touhy, Jett & Luggen, 2008, p. 391). • Eileen will monitor her pain level before engaging in activity and take prescribed medication as needed. • She will maintain appropriate fluid levels and diet with adequate amounts of protein. • Proper protein intake has been associated with retaining muscle (Benefield & Higbee, 2007). • While engaging in activity, Eileen will also rest in between periods of activity.

21. Evaluation: Teach-Back Method • The teach-back method will be used to evaluate Eileen’s understanding of the plan of care • Allow for discussion and clarification if she does not understand what she has learned. • Ensure she is successful utilizing her new skills. • She will repeat what she was taught regarding exercises, relaxation exercises, and the numeric rating scale for pain, using her own words (Cornett, 2009).

22. Evaluation Continued • By the end of the month Eileen should verbalize improved pain control by implementing a pain schedule and demonstrating relaxation techniques. • She will also report improved sleep with the help of sleep routine including a bedtime snack, warm beverage before bed and calm environment in 4 weeks. • Eileen will demonstrate improved mobility and endurance in 6 weeks. • Within one month she will demonstrate the ability to perform active range of motion exercises and proper nutritional intake

23. . Public policy proposal • Despite her family’s protests, Eileen wants to remain in her own home. • She lives in a home older than 100 years which requires a lot of maintenance and upkeep. • As she ages, her home also becomes a safety concern.

24. Public Policy Proposal • A concern for Eileen regarding possible public policy change relates to her living independently in an older home. • If an elderly person is receiving social security and Medicare benefits, a program needs to be in place to evaluate the home for safety and efficiency. • The Aging report states, “we must make it easier for less wealthy older homeowners to occupy more supportive housing arrangements by assisting them with their moving plans and by better informing them and the professionals who serve them about their benefits,” (Golant, 2009). • The program should not force the elderly from their homes, however, offer support, education and alternatives to living in a home that may be difficult to sustain. • Additionally, the program could offer incentives to the homeowners who decide to down-size and seek alternative housing options.

25. Conclusion • The assessment of Eileen reveals she is quite healthy. • Chronic pain from osteoarthritis affects her overall wellbeing, including sleep and physical mobility. • Developing a plan of care with measurable goals and collaborative interventions will allow her to remain independent. • At the same time, public policy changes pertaining to elderly persons living in older homes must be explored to empower and support clients to make affordable and safe housing decisions.

26. References • Benefield, L.E. & Higbee, R.L. (2007). Frailty and its implications for care. Hartford Institute or Geriatric Nursing. ConsultGeriRN.org. • Cornett, S. (2009). Assessing and addressing health literacy. The Online Journal of Issues in Nursing, 14(3). • Cox, H.C., Hinz, M.D., Lubno, M.A., Newfield, S.A., Ridenour, N.A., Slater, M. M., & • Sridaromont, K.L. (1993). Clinical Applications of Nursing Diagnosis: Adult, Child, Women’s Psychiatric, Gerontic, and Home Health Considerations (3rd ed.). Philadelphia: F.A. Davis Company. • Ebersole P., Hess, P., Touhy, T., Jett, K., & Luggen, A. S. (2008). Toward healthy aging: human needs and nursing r esponse. St. Louis: Mosby. • Flaherty, E. (2008). How to try this: using pain-rating scales with older adults. AmericanJournal of Nursing, 108(6), p. 40-47.

27. References • Fulmer, T. (2007). How to try this: Fulmer SPICES. American Journal of Nursing,107(10), p. 40-48. http://www.nursingcenter.com/prodev/cearticle.asp?ti d = 742423. • Geriatric Depression Scale. Retreived from: http://www.stanford.edu/~yesavage/GDS.html • Golant, S.M. (2009). Aging in place solutions for older Americans: Groupthink responsesnot always in their best interest. Public Policy and Aging Report, 19(1). • Graf, C. (2008). How to try this: The Lawton Instrumental Activities of Daily Living Scale.American Journal of Nursing, 108(4), p. 52-62. • Greenberg, S.A. (2007). How to try this: The Geriatric Depression Scale: short form. AmericanJournal of Nursing, 107(10), p. 60-69.

28. References • Grossman, S. & Lange, J. (2006). Theories of aging as basis for assessment. MedSurg Nursing, 15(2), p. 77-83. • Lawton, M.P., & Brody, E.M. (1969) Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9, p. 179- 186. • Omizo, M.M., B.S., Kim, & N.R. Abel. (2008). Asian and European American cultural values, bicultural competence, and attitudes toward seeking professional psychological help among Asian American adolescents. Journal of Multicultural Counseling and Development, 36(1), p.15-28.