Post on 06-Apr-2018
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Geriatrics Part #2
PRN 0093Christensen-Kockrow
Foundations of Nursing
Chapters 38 and 39
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Long-Term Care
Long-term care is defined by the AmericanNurses Association (ANA) as the provision of
physical, psychologic, spiritual, social, and
economic services to help people attain,
maintain, and regain their optimum level of
functioning.
Long-term care is provided in a variety of
settings and offers a broad spectrum of
services.
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Setting for Long-Term Care
The Home Most older adults live in a home setting, with only a
small percentage of those aged 65 or older residing inan institutional setting.
Care of the older adult at home may involve a greatdeal of participation from loved ones.
It costs approximately half as much to care for an olderadult at home as it would cost in a long-term care
facility. Home patients may require only minimal assistance, or
they might receive complex medical therapies.
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Figure 38-1
Family is important in helping to maintain quality of life for the older adult.
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Setting for Long-Term Care
Hospice Provides services to patients and families as the end
of life approaches.
The philosophy of maintaining comfort as death
approaches is central to hospice care.
Provide nursing interventions to meet basic needs;ADLs; pain and symptom management; and spiritualand psychosocial support for the patient, family, and
significant others. Care providers include CNAs, HHAs, LPN/LVNs, and
RNs.
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Setting for Long-Term Care
Adult Daycare Community-based programs are designed to meet the
needs of functionally or cognitively impaired adultsthrough an individualized plan of care.
These structured, comprehensive programs provide avariety of services, including physical care, mentalstimulation, socialization, assistance with healthmaintenance, and health referrals, during any part of
the day but providing less than 24 hours care. They are designed to serve adults who require
supervision, social opportunities, or assistance due toa physical or cognitive impairment.
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Figure 38-2
Available settings that provide long-term care services.
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Setting for Long-Term Care
Residential Care Settings Primarily an older adult population, offering a wide
variety of services
Assisted living
A type of residential care setting whereby the adultpatient rents a small one-bedroom or studio-typeapartment and can receive several personal careservices
Continuing care retirement communities Offer a complete range of housing and health care
accommodations, from independent living to 24-hourskilled nursing care
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Setting for Long-Term Care
Institutional Settings
Subacute Unit
This type of institutional setting provides a less-
expensive alternative to acute care when patients havehigh-acuity medical and nursing intervention needs.
Most are located in freestanding skilled nursing facilities;others are former hospital units that have beenreclassified to provide subacute care.
They provide a stronger rehabilitative focus and shorterlength of stay than a long-term care facility.
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Setting for Long-Term Care
Institutional Settings
Long-Term Care Facility
Most dominant setting for long-term care services
Commonly known as a nursing home or extended carefacility
Provides services to primarily older adults
Provides 24-hour care to individuals who do not require
inpatient hospital services but who do not have optionsfor care at home or by other communityagencies/services
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Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Because the long-term care facility becomes a home for
the older adult, the adults are referred to as residentsrather than as patients.
Most residents have more than one health disorderwhen they are admitted, and more than half have threeor more medical diagnoses.
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Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
The most common disorders on admission are as
follows Cardiovascular disease, including hypertension and
cerebrovascular accident
Mental and cognitive disorders, including depression,anxiety, and dementia
Endocrine disorders, including type 2 diabetes mellitus andhypothyroidism
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Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Two categories of residents
Short-term: transferred from an acute care facility to whichhe or she had been admitted for an acute illness orworsening of a chronic illness; admitted primarily forrehabilitation and expected to be discharged within 6months
Long-term: usually stays in the facility until he or she diesor is transferred to an acute care facility. Most residents arelong term.
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Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Interdisciplinary setting
Health care professionals work together as aninterdisciplinary team to meet the needs of the older adult.
Facility is managed by an administrator and has adirector of nursing (DON).
These facilities are highly regulated by state and federalagencies to ensure quality services to a potentiallyvulnerable population.
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Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Restorative nursing care
Basic concepts of physical therapy for maintenance offunctional mobility and physical activity; care is provided byCNAs who have completed an educational program forrestorative care
OmnibusBudget Reconciliation Act (OBRA)
Defines requirements for the quality of care given toresidents of long-term care facilities
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Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Medicare
A federally funded national health insurance program in theUnited States for people over age 65
Provide funding to long-term care facilities by adhering tothe HCFA guidelines for reimbursement
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Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Medicaid
A federally funded, state-operated program of medicalassistance to people with low incomes
A large source of revenue for the long-term care facility
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Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Several different types of nursing can be seen in this
setting Team nursing
Functional nursing
Total resident care
Combination of the above
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Setting for Long-Term Care
Institutional Settings (continued) Long-Term Care Facility
The interdisciplinary functional assessment of theresident is the cornerstone of clinical practice.
Resident Assessment Instrument (RAI) OBRA-prescribed method of resident assessment and care
plan development
Consists of three parts
Minimum Data Set (MDS)
Resident Assessment Protocols (RAP)
Utilization Guidelines
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Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Documentation of the residents condition including vital
signs and weights, is only required on a monthly basis. The exception to this charting is a condition change,
acute illness, or incident reporting, which must bedocumented at or soon after the time of occurrence.
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Nursing Process
Nursing Diagnoses Aspiration, risk for
Airway clearance, ineffective
Gas exchange, impaired
Cardiac output, decreased
Nutrition: less than body requirements
Fluid volume, risk for deficient
Incontinence Thought process, disturbed
Confusion, chronic
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Nursing Process
Nursing Diagnoses (continued)
Self-care deficit
Injury, risk for
Mobility, impaired physical
Skin integrity, risk for impairment
Self-esteem, chronic low
Grieving Anxiety
Social isolation
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Issues in Rehabilitation
Quality of Life versus Quantity of Life Rehabilitation focuses on continually improving
the quality of the persons life, not merely
maintaining life itself.
Care versus Cure
Many conditions are irreversible; therefore, thefocus of care is related to adaptation and
acceptance of an altered life rather than toresolving an illness.
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Rehabilitation Defined
The process of restoring the individual to thefullest physical, mental, social, vocational,and economic capacity of which he or she iscapable
Relearning of former skills; learning new skillsnecessary to adapt and live fully in an alteredlifestyle
Must begin from the very onset of a traumaticevent or diagnosis of a chronic illness
Every aspect of the individuals needs andcare assessed and addressed
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Issues in Rehabilitation
High Cost of Interdisciplinary Care versusLong-term Care
Rehabilitation is expensive. Success is sometimesseen as a return to productive employment; may
be if the individual becomes sufficientlyindependent that no caregiver is required.
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Need for Rehabilitation
Need for Rehabilitation Precipitated by Impairment
Any loss or abnormality of psychologic, physical, oranatomic structure or function
Disability Any restriction or lack of an ability to perform an activity
in the manner or within the range considered normal fora human being
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Need for Rehabilitation
Handicap A disadvantage for a given individual resulting from an
impairment or disability that limits or preventsfulfillment of a role that is normal for that particularindividual
Functional limitation Any loss of ability to perform tasks and obligations of
usual roles and normal daily life
Chronic illness An irreversible presence, accumulation, or latency of
disease states or impairments that involves the totalhuman environment
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Goals of Rehabilitation
All Rehabilitation Goals Shall maximize the quality of life of the individual
address the individuals specific needs
assist the individual with adjusting to an altered
lifestyle be directed toward promoting wellness and minimizing
complications
assist the individual in attaining the highest degree of
function and self-sufficiency possible assist the individual to return to home and community
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Cornerstones of Rehabilitation
The cornerstones of rehabilitation may be seen asstepping stones on the road to recovery
Individually centered
Community reentry
Independence Functional ability
Team approach
Quality of life
Prevention and wellness Change process
Adaptation
Patient/family education
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Rehabilitation Team
Models of Team Functioning Multidisciplinary Rehabilitation Team
Characterized by discipline-specific goals, clearboundaries between disciplines, and outcomes that are
the sum of each disciplines efforts Interdisciplinary Rehabilitation Team
Collaborates to identify individuals goals and is
characterized by a combination of expanded problem
solving beyond discipline boundaries and discipline-specific work toward goal attainment
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Rehabilitation Team
Models of Team Functioning (continued) Transdisciplinary Rehabilitation Team
Characterized by the blurring of boundaries betweendisciplines, as well as by cross-training and flexibility to
minimize duplication of effort toward individual goalattainment
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Rehabilitation Team
Rehabilitation Nurse Must have a broad knowledge base of
pathophysiology of a wide range of medical-surgicalconditions and a body of highly specialized knowledgeand skills regarding rehabilitation
Must believe that individuals with functional disabilitieshave an intrinsic worth that transcends their disabilities
Specialized training necessary for the rehabilitationnurse to become an effective team member
Practices in a variety of settings
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Rehabilitation Team
Comprehensive Rehabilitation Plan
This is an overall individualized comprehensiverehabilitation plan of care.
It is initiated within 24 hours of admission andready for review and revision by the team within 3days of admission for each individual.
The plan is developed based on the results of the
interdisciplinary admission assessment. All clinicians treating the patient will use this
comprehensive plan of care.
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Patient Education
Crucial for the rehabilitation process to becomprehensive
An ongoing and integral process by which
patients and families build knowledge, skills,and confidence to regain physical and
psychosocial functioning following an illness
or injury
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Patient Education
The following five-step process may be used.
Assess the patient's and familys needs, abilities,
and concerns.
Plan interventions based on these needs, abilities,and concerns.
Implement the educational plan.
Evaluate the educational plan.
Review the educational plan.
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Scope of Individuals Requiring
Rehabilitation Rehabilitation is a bridge for the patient,
spanning the gap between
uselessness and usefulness
hopelessness and hopefulness despair and happiness
The scope of conditions requiring
rehabilitation is broad and spans the lifecontinuum.
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Family and Family-Centered Care
A philosophy that recognized the pivotal roleof the family in the lives of children withdisabilities and other chronic conditions
Strives to support families in their natural
caregiving roles by building on their uniquestrengths as individual parents
Promotes normal patterns of living at homeand in the community and views families andprofessionals as equals in a partnershipcommitted to excellence at all levels of healthcare
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Family and Family-Centered Care
Key Elements of Family-Centered Care
Incorporating into policy and practice therecognition that the family is the constant in a
childs life Facilitating family/professional collaboration at all
levels of hospital, home, and community care
Exchanging complete and unbiased information
between families and professionals in asupportive manner at all times
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Family and Family-Centered Care
Key Elements of Family-Centered Care(continued)
Encouraging and facilitating family-to-family
support and networking Appreciating families as families and children as
children; recognizing that they possess a widerange of strengths, concerns, emotions, and
aspirations beyond their need for specializedhealth and developmental services and support
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Gerontologic Rehabilitation Nursing
This specialty practice focuses on the uniquerequirements of older adult rehabilitation patients.
The gerontologic rehabilitation nurse is knowledgeableabout both techniques of caring for the aged and
rehabilitation concepts and principles.
The main goal is to assist older adult patients inachieving their personal optimal level of health and well-being by providing holistic care in a therapeutic
environment.