Stress
The body's response to physical stressors
Ex: pain, excessive noise, starvation, infection
What are some risk factors for chronic illness
Smoking, obesity, age, physical inactivity, lifestyle, lack of health care, genetic risk factors, economic stability, gender, health literacy, ethnicity, etc.
Describe an Advance Directive
Written documents that state information about the patient’s future health care decisions or choices. Guide for families, HCP, and caregivers on the patients’ goals and wishes for care.
Special Considerations: Document takes various forms, Should adhere to guidelines in the state of residence
What is a living will?
Lay term for a written legal document that describes the patient’s preferences about future health care decisions or choices.
Special Considerations: Must identify specific treatments that a person wants or does not want at EOL
What is the issue with medication compliance in older adults & What are the barriers to it?
Medication use in older adults requires thorough and regular assessment, care planning, and evaluation. Nonadherence to medication plans by older adults may occur due to the inability to read prescription drug labels and/or understand the health information that we provide them.
Barriers to Proper Adherence:
Decreased vision
Forgetting to take drugs
Taking drugs incorrectly
Use of drugs prescribed for someone else
Lack of financial resources to obtain prescription drugs
Refusal to take a drug because of undesirable side effects
Failure to understand instructions or importance of drug treatment
Describe Emotional/Psychological Stress & Give Examples
The body’s response to emotional stressors
Can be positive or negative
Ex: diagnosis of cancer, death of spouse, caring for disabled child, marital problems
What is the patient education related to chronic illness?
Seven tasks of chronic Illness (Corbin & Strauss)
1. Preventing and managing a crisis
Understanding potential for crisis and how to prevent or modify the threat
2. Carrying out prescribed treatment regimen
May be challenging (degree of difficulty) or impact lifestyle (time consuming)
3. Controlling symptoms
Modify lifestyle or living situation to maintain safety
4. Reordering time
Change schedules and/or eliminate activities
5. Adjusting to changes in the course of disease
Include chronic illness as part of identity and make necessary lifestyle changes
6. Preventing social isolation
Patient chooses to withdraw or others don’t associate with patient
7. Attempting to normalize interactions with others
Manage symptoms to hide disability/disfigurement
Describe an Allow Natural Death (AND) document
Preferred term for a do-not-resuscitate order. Acknowledges the patient’s wish to avoid aggressive measures. May be associated with care focusing on dignity and comfort.
Special Considerations: May be called do not attempt resuscitation (DNAR) in some states or agencies
What is a Physician/Practitioners Order for Life-Sustaining Treatment (POLST)?
Legal form completed by the patient and HCP listing treatments wanted, not wanted, or limited. Guides current treatment and acts as medical orders across health care settings
Special Considerations: State specific form; May be signed by a physician and/or nurse practitioner (varies by state), and patient or patient surrogate; Also called Medical Order for Life-Sustaining Treatment (MOLST)
Describe how to guarantee safe use of medications in older adults
When older adults are using medications, it is important to take the following measures to prevent medication errors:
Assess cognitive function and monitor for changes.
Assess their ability to self-administer medication
Obtain and maintain a complete medication record.
Assess for alcohol and illicit drug use.
Encourage the use of written or electronic medication-reminder systems.
Encourage the use of 1 pharmacy.
Work with HCPs and pharmacists to set up routine drug profiles on all older adult patients.
Try to reduce drug use that is not essential by consulting the HCP and pharmacist.
Advocate for low-income prescription support services.
Managing emotions that one feels when a stressful event occurs
Managing emotions that one feels when a stressful event occurs
Examples of emotion-focused coping: discussion of feelings with a friend or taking a hot bath
Although it may not seem to be working toward a solution, emotion-focused coping is a valid and appropriate way to deal with
What are the physical manifestations of the end of life?
Physical manifestations of End Of Life
Metabolism is decreased.
Body gradually slows down until all function ends.
Respiration generally ceases first.
Heart stops beating within a few minutes.
Irregular breathing which gradually slows
Cheyne-Stokes respiration
Inability to cough or clear secretions
Grunting, gurgling, or noisy congested breathing (“death rattle”)
Hearing is usually last sense to disappear.
Decreased sensation
Decreased perception of pain and touch
Blurring of vision
Blink reflex absent
Patient appears to stare.
Eyelids remain half-open.
Decreased sense of taste and smell
Mottling on hands, feet, arms, and legs
Cold, clammy skin
Cyanosis of nose, nail beds, knees
“Waxlike” skin when very near death
Gradual decrease in urinary output
Incontinent of urine
Unable to urinate
Can have pt who urinates or has bowel movement after passing
Slowing of digestive tract and possible cessation of function
Accumulation of gas
Distention and nausea
Loss of sphincter control
Bowel movement may occur before imminent death or at the time of death
Gradual loss of ability to move
Trouble holding body posture and alignment
Loss of facial muscle tone
Sagging of jaw
Difficulty speaking
Loss of gag reflex
Swallowing can become more difficult.
Increased heart rate
Later slowing and weakening of pulse
Irregular rhythm
Decreased blood pressure
Delayed absorption of IM or SQ drugs
Altered decision making
Anxiety and fear
Life review
Peacefulness
Saying goodbyes
Withdrawal
What is combined directives?
Includes more than 1 form. Contain directives about health care, values/goals, and/or appointed health care proxy. Example includes the “Five Wishes” advance directive.
Special Considerations: Not considered a legal document in all states; May be used to start discussion about advance directives between patient, family, and HCP
Describe older adult interviews & assessments
Assessment
First attend to primary needs
Ensure assistive devices are used
Allow plenty of time
Interview family or caregivers separately
Geriatric assessment involves an interprofessional approach
Team findings and recommendations are presented to the patient and family
Complete nursing assessment
Thorough history
Mood assessment
Functional assessment with ADLs and IADLs
Mental status evaluation
Social-environmental assessment
Physical assessment
SPICES
Describe Problem-Focused Coping
Find solutions to resolve problems causing stress
Examples of problem-focused coping: setting priorities, collecting information, and seeking advice
What does brain death entail?
Brain death is a clinical diagnosis. It occurs when the cerebral cortex stops functioning or is irreversibly destroyed. The diagnostic criteria for clinical diagnosis of brain death include coma or unresponsiveness, absence of brainstem reflexes, and apnea.Physicians perform specific assessments to confirm each criterion. Current legal and medical standards require that all brain function cease to be able to pronounce brain death. Diagnosing brain death is of special importance when organ donation is an option.
What is entailed with a do not resuscitate (DNR) document?
Written order reflecting a patient’s wish to avoid or not attempt CPR
Special Considerations: Signed by a physician or nurse practitioner (varies by state), Record that discussion was held
Describe how can relaxation strategies can be used for stress and give examples
Relaxation strategies can be used to cope with stressful circumstances and elicit the relaxation response.
Relaxation strategies can include
Relaxation breathing
Meditation
Imagery
Music for relaxation
Massage.
Describe the pain control in pts who are terminally ill
The goal of adequate pain control in seriously ill or terminally ill is based on the principle of nonmaleficence, to ease suffering (preventing or reducing harm to the patient). Access to adequate pain and symptom management at EOL follows the principle of beneficence, which includes promoting good. Since the intent of this action is to ease suffering, not hasten death, it is ethically justified by the principle of double effect. Though administering opioids and sedatives at the end of life may cause sedation, it is justified to relieve suffering.
What is a durable power of attorney for health care (DPAHC)?
Defines who will serve as the surrogate decision-maker when the patient loses decision-making capacity.
Special Considerations: Also called medical power of attorney, health care proxy, appointment of a health care agent or surrogate; Does not include financial decisions