Balas, PhD, RN, APRN-NP, Assistant Professor CCRN, University of Nebraska Medical Center (UNMC), Omaha, NE. Mentes, PhD, APRN, BC, FGSA Associate Professor, University of California, Los Angeles, Los Angeles, CA.
Protocols for Best Practice
1 Clinical decision-making based on the best available evidence is essential to promote patient safety and quality of healthcare outcomes. In the third edition and this fourth edition, the process previously used to develop geriatric nursing protocols has been improved.
Developing and Evaluating Clinical Practice Guidelines
In the second edition of this book, Lucas and Fulmer (2003) challenged geriatric nurses to take the lead in evaluating geriatric clinical practice guidelines (CPGs), recognizing that guidelines and protocols have little value for clinical use in the absence of the best of evidence. decision making. In the third edition of this book, Levin, Singleton, and Jacobs (2008) proposed a method to ensure that the protocols included in the book are based on a systematic review of the literature and a synthesis of the best evidence.
A Systematic Approach
There was no standard process or specific criteria for protocol development, nor was there any indication of the “level of evidence” of each source cited in the chapter (i.e., the evidence base for the protocol). Nadzam and Abraham (2003) state that “the main purpose of implementing best practice protocols for geriatric nursing is to encourage nurses to practice with greater knowledge and skills, and thus improve the quality of care for older adults” ( p.11).
Measuring Performance, Improving Quality
Healthcare consumers and providers are often asked, "What does quality mean to you?" The answer usually varies and includes statements such as. The IOM defines quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Kohn, Corrigan, & Donaldson, 2000, p. 211). .
Age-Related Changes in Health
Age-Related changes in Health
- GOAL: To identify anatomical and physiological changes, which are attributed to the normal aging process
- OVERVIEW: Age-associated changes are most pronounced in advanced age of 85 years or older, may alter the older person’s response to illness, show great variability among
- STATEMENT OF PROBLEM: Gerontological changes are important in nurs- ing assessment and care because they can adversely affect health and functionality and
- AGE-ASSOCIATED CARDIOVASCULAR CHANGES A. Definition(s)
- AGE-ASSOCIATED CHANGES IN THE PULMONARY SYSTEM A. Etiology
OVERVIEW: Age-related changes are most pronounced at advanced age of 85 years or older, may alter the older person's response to disease, show large variation between years or older, may change the elderly person's response to disease, show large variation among individuals, are often influenced by genetic and long-term lifestyle factors and commonly involves a decrease in functional reserve with reduced response to stressors. ISSUE: Gerontological changes are important in nursing assessment and care because they can have a negative impact on health and functionality and assessment and care because they can negatively affect health and functionality and require therapeutic strategies; must be differentiated from pathological processes to enable the development of appropriate interventions; predispose to disease, which emphasizes the need for risk assessment of the older adult; and may interact reciprocally with disease, resulting in altered disease presentation, response to treatment, and outcomes.
Age-Related Changes in Health (cont.)
- AGE-ASSOCIATED CHANGES IN THE RENAL AND GENITOURINARY SYSTEMS
- AGE-ASSOCIATED CHANGES IN THE OROPHARYNGEAL AND GASTROINTESTINAL SYSTEMS
- AGE-ASSOCIATED CHANGES IN THE MUSCULOSKELETAL SYSTEM A. Definition(s)
Administration on Aging http://www.aoa.gov National Institute on Aging http://www.nia.nih.gov Nonprofits Health and Age Foundation http://www.healthandage.org. Association for Research on Aging http://www.agingresearch.org National Council on Aging http://www.ncoa.org.
Sensory Changes
A cataract appears as a dark shadow in the front part of the lens in front of the retina. Sensorineural hearing loss is the most common form of hearing loss in older adults (Linton, 2007), involving damage to the inner ear, cochlea, or fibers of the eighth cranial nerve. Because of the impact on quality of life, a complete history and physical examination is important in older adults.
The Individualized Sensory Enhancement of the Elderly (I-SEE) program was developed to tailor nursing interventions to the type and level of sensory impairment experienced by the older adult (Wilensky & Hawkins, 2001).
Excessive Sleepiness
- GOAL: Older adults will maintain an optimal state of alertness while awake and optimal quality and quantity of sleep during their preferred sleep interval
- OVERVIEW: Although normal aging is accompanied by decreased “deep sleep,”
- BACKGROUND A. Definition
- PARAMETERS OF ASSESSMENT
Daytime sleepiness is not only a symptom of sleep disorders, but also results in reduced health and functional outcomes in older adults. There are many types of sleep diagnoses, and the most common disorders reported by older adults are obstructive sleep apnea (OSA), insomnia, and restless legs syndrome. Many sleep disorders share excessive sleepiness as a common symptom, but this symptom is often not assessed or treated because health care providers are not informed about the nature of sleep disorders, the symptoms of these disorders, and the many effective treatments available for these disorders. conditions. .
For patients with a current diagnosis of a sleep disorder, ongoing treatments such as continuous positive airway pressure (CPAP) should be documented, maintained, and reinforced through patient and family education (Avidan, 2005).
Excessive Sleepiness (cont.)
- EVALUATION AND ExPECTED OUTCOMES A. Quality Assurance Actions
- FOLLOW-UP MONITORING
Improved sleep quality and/or quantity during normal sleep intervals as reported by patients and staff. This free online subscription service is an excellent resource for professionals to regularly find the latest research on sleep disorders and their treatment. It is an excellent resource for nurses interested in studying sleep issues and circadian processes.
Treatment of sleep disorders should include planning strategic lifestyle changes that include regular exercise, which is also consistent with cardiovascular health and long-term diabetes control (Ancoli-Israel & . Ayalon, 2006).
Assessment of Physical Function
Assessment of Physical function
- GOAL: The following nursing care protocol has been designed to help bedside nurses to monitor function in older adults, prevent decline, and maintain the function
- OBJECTIVE: To maximize physical functioning, prevent or minimize decline in activity of daily living (ADL) function, and plan for transitions of care
- BACKGROUND
- ASSESSMENT PARAMETERS
- CARE STRATEGIES
These declines are usually reversible and require medical evaluation (Applegate et al., 1990; Sager & Rudberg, 1998). Additional complications of functional decline include loss of independence, falls, incontinence, malnutrition, decreased socialization, and increased risk for long-term institutionalization and depression (Covinsky et al., 1998; Creditor, 1993; Landefeld et al., 1995). Assessment of functional status helps plan future care needs after hospitalization, such as skilled short-term care, home care, and the need for community services (Graf, 2006; Landefeld et al., 1995).
Encourage walking, allow flexible visitors, including pets, and encourage newspaper reading (Kresevic & Holder, 1998; Landefeld et al., 1995).
Assessment of Physical Function (cont.)
- ExPECTED OUTCOMES A. Patients can
- RELEVENT PRACTICE GUIDELINES
Explore alternatives to using physical restraints (Covinsky et al., 1998; Kresevic . & Holder, 1998; see Chapter 13, Physical Restraints and Side Rails and Critical Care Settings). Provides information to caregivers about causes of functional decline associated with acute and chronic conditions (Covinsky et al., 1998). Short-term skilled physical therapy care may be needed; long-term care settings may be necessary to ensure safety (Covinsky et al., 1998).
Immobility associated with functional decline results in infections, pressure ulcers, falls, persistent reductions in function and physical activity, and non-elective re-hospitalizations (Gill et al., 2004).
Interventions to Prevent Functional Decline in the
As described in Chapter 6, Assessing Function, functional decline is a common complication in older hospitalized patients, even in those with good baseline function (Gill, Allore, Gahbauer, & Murphy, 2010). Loss of physical function is associated with poor long-term outcomes, including increased likelihood of discharge to a nursing home (Fortinsky, Covinsky, Palmer, & Landefeld, 1999), increased morbidity and mortality (Boyd, Xue, Guralnik, & Fried , 2005; Rozzini et al., 2005), increased rehabilitation costs and decreased functional recovery (Boyd et al., 2008; . Boyd et al., 2005; Gill, Allore, Holford, & Guo, 2004; Volpato et al. , 2007). Promoting function is a fundamental tenet of gerontology, and functional status is a key determinant of quality of life for older adults (Boltz, Capezuti, Shabbat, & Hall, 2010).
Although the acute care environment, with its focus on correcting the admitted medical problem, typically prioritizes nursing tasks such as medication administration, care coordination and documentation over promoting function as a clinical outcome, there is a growing awareness of the need. to take care of the functional status of the hospitalized older adult (Nolan & Thomas, 2008).
Acute Care Setting 7
- GOAL: The following protocol has been designed to help nurses collaborate with the interdisciplinary team to implement interventions that maximize the older adult’s
- OBJECTIVE: As stated in Chapter 3, to restore or maximize physical functioning, prevent or minimize decline in ADL function, and plan for transitions of care
- FUNCTION-FOCUSED CARE INTERVENTIONS A. Hospital care systems and processes
Functional decline is a common complication in hospitalized older adults, even in those with good baseline function (Gill et al., 2010). Functional decline may result from the acute illness and may begin preadmission (Fortinsky et al., 1999) and continue after discharge (Sager et al., 1996). Interdisciplinary rounds support promotion of function by addressing functional assessment (baseline and current), evaluating potentially limiting devices and agents, and producing a plan for progressive mobility (McVey et al., 1989).
FFC educational intervention in medical-surgical units have shown improvements in knowledge and outcome expectations related to function-promoting care (Resnick et al., 2011).
Function-Focused Care (FFC) Interventions (cont.)
- ExPECTED OUTCOMES A. Patients will
- RELEVANT PRACTICE GUIDELINES
Interdisciplinary rounds address functional assessment (baseline and current), evaluate potentially limiting aids and factors, and provide a plan for progressive mobility (McVey et al., 1989). Toilets, beds and chairs at an appropriate height to promote safe transfer and function (Capezuti et al., 2008). Adequate lighting, glare-free floors, door handles, and handrails (including in the patient room; Gulwadi & Calkins, 2008; Ulrich et al., 2008).
Recovery of activities of daily living in the elderly after hospitalization for acute medical illness.
Assessing Cognitive Function
Assessing cognitive functioning
- GOAL: The goals of cognitive assessment include
- OVERVIEW
- BACKGROUND AND STATEMENT OF PROBLEM
- ASSESSMENT OF COGNITIVE FUNCTION A. Reasons/Purposes of Assessment
Assessment of cognitive function is the basis for early detection and prompt treatment of impairment (Shekelle et al., 2001). Naturally occurring interactions: Observations and conversations during naturally occurring caregiving interactions may prompt additional screening/monitoring of cognitive function with the MMSE or Mini-Cog (Foreman et al., 2003). On admission to and discharge from an institutional care setting (British Geriatrics Society Clinical Guidelines, 2005; Shekelle et al., 2001).
Before important health care decisions are made in addition to determining an individual's ability to consent (Shekelle et al., 2001).
Assessing Cognitive Functioning (cont.)
Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE) is useful to supplement testing with the MMSE or Mini-Cog, as it is useful in determining the onset, duration and functional impact of the cognitive impairment. Current opinions regarding the importance, diagnosis and management of delirium in the intensive care unit: A survey of 912 health professionals. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): Development and cross-validation.
Despite the effective treatments available for late-life depression, many older adults do not have access to adequate resources; Barriers in the health care reimbursement system pose a particular challenge for low-income and ethnic minority older adults (Charney et al., 2003).
Depression in Older Adults
Depression in Older Adults
- BACKGROUND*
- ASSESSMENT PARAMETERS A. Identify risk factors/high risk groups
- CARE PARAMETERS
Specific comorbid conditions: dementia, stroke, cancer, arthritis, hip fracture, myocardial infarction, chronic obstructive pulmonary disease and Parkinson's disease (Alexopoulos et al., 2005; Butters et al., 2003). Treatment options may include medication or cognitive behavioral therapy, interpersonal or brief psychodynamic psychotherapy/counseling (individual, group, family); hospitalization; or electroconvulsive therapy (Areán & Cook, 2002; Hollon et al., 2005). For less severe depression (GDS score 6 or higher, less than five depressive symptoms plus other positive responses on individualized assessment), referral to mental health services for psychotherapy/counseling (see previous types), especially for specific problems identified in individualized assessment and to determine whether medication therapy may be warranted.
If suicidal ideation, psychosis, or concomitant substance abuse are present, a referral for a comprehensive psychiatric evaluation should always be made (Areán & Cook, 2002; Hollon et al., 2005).
Depression in Older Adults (cont.)
- EVALUATION OF ExPECTED OUTCOMES A. Patient
- FOLLOW-UP TO MONITOR CONDITION
Challenges associated with recognizing and treating depression in elderly home care service recipients. Diagnosis and treatment of depression in late life a summary of the NIH consensus statement. Treatment of depression in older adults in the primary care setting: An evidence-based review.
Collaborative care management of late-life depression in primary care: a randomized controlled trial.
Dementia
Recognition and Management of Dementia
- GOALS
It is imperative that a differential diagnosis be established early in the course of cognitive impairment and that the patient be monitored closely for co-existing morbidities. Dementia is a clinical syndrome of cognitive deficits that includes both memory impairment and a disturbance in at least one other domain of cognition, such as aphasia, apraxia, agnosia, and disturbance in executive functioning. The Clock Drawing Test (CDT) is a useful measure of cognitive function related to executive control functions.
A comprehensive physical examination focusing on the neurological and cardiovascular system is indicated in persons with dementia to identify the potential cause and/or the existence of a reversible form of cognitive impairment.
Recognition and Management of Dementia (cont.)
- NURSING CARE STRATEGIES
- EVALUATION/ExPECTED OUTCOMES
- FOLLOW UP TO MONITOR CONDITION
- RELEVANT PRACTICE GUIDELINES
Integrate community resources into the care plan to meet patient and caregiver information needs; identify and facilitate formal (eg, Alzheimer's Association, respite care, specialized long-term care) and informal (eg, churches, neighbors, extended family/friends) support systems. The role of proteoglycans and glycosaminoglycans in the pathogenesis of Alzheimer's disease and related disorders: amyloidogenesis and therapeutic strategies - a review. Efficacy of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer's disease.
Efficacy of galantamine in probable vascular dementia and Alzheimer's disease combined with cerebrovascular disease: a randomized trial.
