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Week 1 discussion

Changes in Sites of Care

Since the culture and practices of care settings are
inherently different, changes in sites of care are often difficult for
geriatric patients. Efforts should be made to limit changes to only those
necessary; however, sometimes a patient’s situation might require multiple
changes in sites of care. When selecting sites of care, such as home, assisted
living, rehabilitation facilities, and hospitals, many factors must be
considered by patients, their families, and their health care providers. Health
status, ability to perform self-care, financial limitations, and patient
preferences are all factors that might influence a patient’s site placement. As
an advanced practice nurse who recommends sites of care and facilitates
changes, you must evaluate factors and consider sites that limit the impact of
these changes on geriatric patients.

To prepare:

Review this week’s media presentation, as well as Chapters 4
and 7 of the Flaherty and Resnick text.

Reflect on your personal experiences, observations, and/or
clinical practices from the last 5 years. Select a case from the last 5 years
that involves an elderly patient who has been in two different sites of care
such as home, assisted living, hospital, etc. Note: When referring to your
patient, make sure to use a pseudonym or other false form of identification.
This is to ensure the privacy and protection of the patient.

Reflect on issues that occurred because of the change in the
patient’s sites of care. Think about the impact of differences in the settings
themselves, inherent cultures of the settings, and ethical practices of these
sites on the patient.

Consider whether the patient had an advanced directive in
place at the time of the change in sites of care. Reflect on whether any
difficult treatment decisions had to be made as a result.

Think about the impact of financial issues on site placement
and treatment decisions.

Post on or before Day 3 a description of a case from your
personal or clinical experiences in the last 5 years that involves an elderly
patient who has been in at least two different sites of care. Explain the
impact of differences in the settings themselves, inherent culture of the
settings, and ethical practices of these sites on the patient. Then, explain
whether the patient had an advanced directive in place at the time of the
change in sites of care, and if so, whether any difficult treatment decisions
had to be made as a result. Finally, explain the impact of financial issues on
site placement and treatment decisions.

Read a selection of your colleagues’ responses.

Respond on or before Day 6 to at least two of your
colleagues on two different days in one or more of the following ways:

Suggest community resources that may assist with related
cases in the future.

Recommend appropriate alternative site placements for your
colleagues’ patients based on your geographic location.

Provide insights on policy implications of your colleagues’
cases (i.e., Medicare, Medicaid, Veteran’s Affairs, etc.).

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Week 2 discussion

Assessment Tools

As geriatric patients age, their health and functional
stability may decline resulting in the inability to perform basic activities of
daily living. In your role as the advanced practice nurse, you must assess
whether the needs of these aging patients are being met. Comprehensive
geriatric assessments are used to determine whether these patients have developed
or are at risk of developing age-related changes that interfere with their
functional status. Since the health status and living situation of geriatric
patients often differ, there are a variety of assessment tools that can be used
to evaluate wellness and functional ability. For this Discussion, consider
which assessment tools would be appropriate for the patients in the following
three case studies:

Case Study 1:

Mr. Smith, age 77, reports for an annual physical
examination. He says he is doing well. His only known problem is
osteoarthritis. He also requests a flu shot. He takes no medications other than
Tylenol for arthritis pain. When he walks into the exam room, you notice that
he is using a straight cane in his right hand. When you ask about the cane, he
says he began using the cane because the pain in his right hip had increased
significantly over the past 6 months.

Case Study 2:

Mr. Jones, a 68-year-old man, was referred to your office
for a hearing evaluation. He continues to work in a printing company, although
he works only part-time. He has worked at the printing company for the past 35
years. He complains that he cannot hear much of the dialogue on the television.
He is accompanied by his wife, who states that her husband cannot hear her at
home. He has no history of dizziness, tinnitus, or vertigo. He has had cerumen
impactions removed from both ears in the past. Overall, his medical history is
quite benign. His only medications are aspirin 81 mg daily, a multivitamin
daily, and occasional ibuprofen for back pain.

Case Study 3:

Mrs. Roberts, an 83-year-old widow, is brought to the office
by her daughter. The daughter claims that her mother seems to be depressed.
There is a history of depression approximately five years ago, shortly after
Mrs. Roberts’ husband died. At that time, she was successfully treated with
antidepressants. Currently, the daughter states that her mother’s memory for
appointments and events has declined severely, and she can no longer drive
because she does not remember the route to the store or other familiar places.
The daughter also noted that her mother’s house seemed very disorganized and
dirty, there was a limited amount of food in the kitchen, and the checkbook had
not been balanced for several months. Mrs. Roberts appears slightly disheveled,
she has a flat affect, and she does not maintain eye contact during your
interview.

To prepare:

Review the Rosen and Reuben article in this week’s Learning
Resources. Consider how assessment tools are used to evaluate patients.

Select one of the three case studies. Based on the provided
information, think about a possible patient evaluation plan. As part of your
evaluation planning, consider where the evaluation would take place, whether
any other professionals or family members should be present, appropriate assessment
tools and guidelines, and any other relevant information you may wish to
address.

Consider whether the assessment tool you identified was
validated for use with this specific patient population and if this poses
issues. Think about additional factors that might present issues when
performing assessments, such as language, education, prosthetics, missing
limbs, etc.

Post on or before Day 3 an explanation of your evaluation
plan for the patient in the case study you selected and explain which type of
assessment tool you might use for the patient. Explain whether the assessment
tool was validated for use with this patient’s specific patient population and
whether this poses issues. Include additional factors that might present issues
when performing assessments, such as language, education, prosthetics, missing
limbs, etc.

Read a selection of your colleagues’ responses.

Respond on or before Day 6 to at least two of your
colleagues on two different days in one or more of the ways listed below.
Respond to colleagues who selected different case studies than you did.

Suggest alternative assessment tools and explain why these
tools might be appropriate for your colleagues’ patients.

Recommend strategies for mitigating issues related to use of
the assessment tools your colleagues discussed.

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Week 3 discussion

Models of Interdisciplinary Geriatric Care Teams

With the growing population of frail elders, there is an
increase of geriatric patients requiring ongoing care for multiple medical
conditions. This creates the need for interdisciplinary geriatric care teams.
Often, the dynamics and culture of these teams differ across various sites of
care, such as assisted living, home care, hospitals, long-term care, and
rehabilitation facilities. As an advanced practice nurse, it is important to
understand your role in the care team as well as your potential impact on
patient care. In this Discussion, you explore models of interdisciplinary
geriatric care teams for different sites of care and the varying roles of the
advanced practice nurse. Consider the following three case studies:

Case Study 1:

Mrs. Martinez is an 83-year-old Mexican American widow who
lives in her own home and is cared for by her adult daughter. Mrs. Martinez
owns the home, and her daughter lives with her and provides the care. Her
daughter brought her mother to the clinic today to ask to speak to the social
worker. She requests that her mother be placed in a nursing home. The daughter
states that her mother has nothing to do during the day. The television is on
The Weather Channel most of the day because Mrs. Martinez has limited English
capability and is unable to read closed-captioning. Mrs. Martinez also has two
sons who do not live in the local area, but they do call regularly and check in
with their mother and sister. The two sons are opposed to moving their mother
to a nursing home because they had promised her that they would “never put her
away.”

Case Study 2:

Mr. Williams, a 79-year-old African American widower,
resides in a foster care home. He has lived there for 4 years since his wife
died. He is a former minister. His medical history includes long-term diabetes,
high blood pressure, and benign prostatic hypertrophy. The home care provider
has requested a home visit to evaluate Mr. Williams’s ability to remain in the
home. The provider states that because Mr. Williams’s vision is seriously
compromised (he is nearly blind), and because he has been unable to get to the
toilet as quickly as necessary (he is very unsteady on his feet), his care is
becoming burdensome. According to the home care provider, for safety reasons,
Mr. Williams may not fit the criteria for remaining in the foster care home.

Case Study 3:

Mrs. Randall is a 77-year-old female who resides in a
long-term care facility. She has a history of frequent falls and is severely
cognitively impaired. The nursing staff at the long-term care facility called
the nurse practitioner at the medical home office to report the recent
development of productive cough and high fever. There have been cases of flu in
the facility; however, Mrs. Randall has had a flu shot. The nurse practitioner
in the office requests a chest x-ray in the long-term care facility. The nurse
on duty in the facility states that there is no portable chest x-ray equipment
available. She further requests that Mrs. Randall be transferred to the emergency
room of the local hospital. Mrs. Randall’s daughter has durable power of
attorney for health care decisions for her mother. The long-term care facility
has notified the daughter of the change in her mother’s condition. The daughter
says whatever the nursing home wants is fine with her.

To prepare:

Review this week’s media presentation, as well as the
American Geriatrics Society and Arbaje et al. articles in the Learning
Resources.

Research models of interdisciplinary geriatric care teams
that are used at various sites, such as assisted living, home care, hospitals,
long-term care, and rehabilitation facilities.

Consider the model used for the interdisciplinary geriatric
care teams at your current practicum site. Compare this model to models used at
other sites.

Reflect on how the role of the advanced practice nurse
differs according to the site of care.

Select one of the three case studies. Consider how care
should be facilitated for the patient in the case you selected based on the
model used for the interdisciplinary geriatric care teams at your practicum
site.

Post on or before Day 3 a comparison of the model used for
the interdisciplinary geriatric teams at your current practicum site to models
used at other sites. Then, explain how the role of the advanced practice nurse
differs according to the site of care. Finally, explain how care should be
facilitated for the patient in the case you selected based on the model used
for the interdisciplinary geriatric teams at your practicum site.

Read a selection of your colleagues’ responses.

Respond on or before Day 6 to at least two of your
colleagues on two different days in one or more of the ways listed below.
Respond to colleagues who selected different case studies than you did.

Offer and support an alternative perspective based on your
own experience and additional literature search.

Validate an idea with your own experience and additional
literature search.

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entering your message. Then click on the Submit button to post your message.

Week 4 discussion

Over-the-Counter Drugs

Pharmacokinetic and pharmacodynamic processes differ among
patients across their life spans. For geriatric patients, alterations due to
aging make them especially prone to adverse drug reactions. The various health
issues that affect many geriatric patients further complicate this, as the need
to treat these multiple health issues often results in polypharmacy. Although
treatments are frequently drugs prescribed by the health care provider, many
geriatric patients also take over-the-counter (OTC) drugs. While the provider
sometimes recommends these OTC drugs, patients often select the drugs on their
own. This makes patient education on pharmacology key when caring for geriatric
patients. Many patients assume that if drugs are available over the counter,
then they are safe to take. However, due to issues related to polypharmacy and
how their aging bodies process drugs, OTC drugs may have serious implications
for patients.

To prepare:

Review the American Geriatrics Society article and
interactive media piece in this week’s Learning Resources.

Select one of the following over-the-counter drugs commonly
used by geriatric patients:

Antacids or acid suppressants

Antidiarrheal

Antihistamines

Antimicrobial ointments

Antispasmodics for the bladder

Cough suppressants

Laxatives

Neutraceuticals (choose one; e.g., ginseng, St. John’s wart,
etc.)

Pain medications (choose one; e.g., acetaminophen,
ibuprofen, rub-on pain ointments/patches, etc.)

Supplements (choose one; e.g., calcium, iron, etc.)

Vaginal creams

Research the over-the-counter drug you selected. Visit a
local pharmacy and explore the types/varieties of the drug that are available.
Reflect on the ingredients in each type/variety, including additional active
ingredients.

Consult with the pharmacist about the ingredients in each
type/variety, including how to make safe and effective clinical decisions in
relation to this drug. Discuss potential interactions in frail elders and
precautions related to the drug based on Beers Criteria. If one is available,
you may consult with a pharmacist at your practicum site as an alternative to
visiting a pharmacy.

Consider ways to educate elders about the OTC drug you
selected.

Post on or before Day 5 a PowerPoint presentation that
addresses the following:

Describe the over-the-counter drug that you selected.

Identify the types/varieties of the drug that are available.
Describe the ingredients in each type/variety including additional active
ingredients.

Explain the key information that you need to know about this
OTC drug to make safe and effective clinical decisions. Include potential
interactions in frail elders and describe any precautions related to the drug
based on Beers Criteria.

Explain how you would educate elders about the OTC drug you
selected.

Read a selection of your colleagues’ responses.

Respond on or before Day 7 to at least two of your
colleagues on two different days in one or more of the ways listed below.
Respond to colleagues who selected a different drug than you did.

Suggest additional interactions in frail elders that may be
caused by the ingredients in your colleagues’ drugs.

Provide insights to drug-drug interactions between the drug
you selected and the drugs your colleagues selected.

Validate an idea with your own clinical experiences and
additional literature search.

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Week 5 discussion

Fall-Risk Assessment

Fall risks are very high for the geriatric population.
According to the Centers for Disease Control and Prevention (2013), one out of
every three adults aged 65 years and older falls each year. This can be
attributed to factors such as changes in aging, other health issues,
environment, and effects of prescribed drugs. When caring for geriatric
patients, it is important to screen them for risks and perform fall-risk
assessments. These assessment tools help to determine the level of risk for
patients so that preventive measures can be taken. The implications of falls
are very serious and range from fractures to mental health disorders and even
death. In this Discussion, you explore risk assessment tools for use with
patients at your practicum site.

To prepare:

Review the Kanis article in this week’s Learning Resources.

Consider a geriatric patient at your practicum site who is
at risk for falls. Coordinate an opportunity to assess this patient with your
Preceptor. Note: When referring to your patient, make sure to use a pseudonym
or other false form of identification. This is to ensure the privacy and
protection of the patient.

In addition to the Fracture Risk Assessment Tool (FRAX),
select one of the following tools to assess this patient for falls:

Tinetti Performance Oriented Mobility Assessment (POMA)

Systems Approach

Berg Balance Scale

Elderly Mobility Scale

Timed Unsupported Stead Stand (TUSS)

Six-Minute Walk Test (6MWT)

Hendrich II Fall Risk Model

Consider why you selected the assessment tool for this
particular patient.

Assess the patient using the tool you selected under
Preceptor guidance. Reflect on the assessment, including any issues with the
patient and/or the effectiveness of the tool.

Think about strategies and interventions to reduce the risk
of falls for frail elders.

Post on or before Day 3 a case study description of a
geriatric patient from your practicum site who is at risk for falls. Describe
this patient’s FRAX assessment. Then, describe the other assessment tool you
used in the fall-risk assessment and explain why you selected the tool for this
particular patient. Explain the patient assessment, including any issues with
the patient and/or the effectiveness of the tool. Finally, explain strategies
to reduce the risk of falls for your patient.

Read a selection of your colleagues’ responses.

Respond on or before Day 6 to at least two of your
colleagues on two different days in one or more of the ways listed below.
Respond to colleagues who selected a different assessment tool than you did.

Suggest alternative tools for assessing your colleagues’
patients.

Recommend additional strategies to reduce the risk of falls
for your colleagues’ patients.

Share insights based on your own experience and additional
literature search.

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entering your message. Then click on the Submit button to post your message.

Week 6 discussion

Patient Presentation of Dementia, Delirium, and Depression

With the prevalence of dementia, delirium, and depression in
the growing geriatric population, you will likely care for elderly patients
with these disorders. While many symptoms of dementia, delirium, and depression
are similar, it is important that you are able to identify those that are
different and properly diagnose patients. A diagnosis of one of these disorders
is often difficult for patients and their families. In your role as the
advanced practice nurse, you must help patients and their families manage the
disorder by facilitating necessary treatments, assessments, and follow-up care.
Consider the patient presentations in the following case studies. What distinct
symptoms or factors would lead you to a diagnosis of dementia, delirium, or
depression?

Case Study 1:

HPI: Mrs. Mayfield is a 75-year-old woman who is brought to
the emergency room by the police at 11 p.m. She was found wandering and
confused in a local neighborhood. The police were called when Mrs. Mayfield
tried to use her key on a neighbor’s door. When confronted by the police she
became abusive, confused, and frightened and looked very pale and agitated. The
police could not establish her correct address and they subsequently brought
her to the emergency room.

Review of Symptoms (ROS): Unable to obtain at this time.

Objective Data:

PE:

VS: Pulse 96 and regular; B/P 150/90; Axillary temperature
99°F.

General: She appears clean and well nourished, with no signs
of injury, trauma, or neglect.

Her physical exam is unremarkable except –

Neuro: No gross focal neurological signs, but she is only
intermittently cooperative. Her mental status fluctuates and a full
neurological evaluation is not possible at this time.

Psych: A & O x 1 to person only. She has episodes of agitation and alternating
withdrawal/somnolence. During the examination, it takes several attempts to
gain Mrs. Mayfield’s attention to answer questions, but once focused, she
rambles on in a disorganized and incoherent way.

Case Study 2:

CC: “irritable and forgetful”

HPI: Mrs. White, a 78-year-old married woman, is brought to
the office of her primary care provider by her husband because of increasing
forgetfulness and irritability over the past 3 months. Mr. White claims that
his wife has had problems for several years now, but has just gotten “worse in
her memory” in the past few months. She recently misplaced her purse and accused
her son of stealing it.

On three occasions, she left the stove on and boiled a pot
dry, nearly causing a fire. She recently put a container of ice cream into the
washing machine instead of into the freezer and her husband did not discover it
for more than a week. Mrs. White claims her family wants to take her money and
leave her with nothing. “No matter what they say, there is nothing wrong with
me,” she states.

Past Medical History (PMH) includes: hypothyroidism, treated
with Synthroid, and successful treatment of breast cancer approximately 15
years prior. She also takes over-the-counter ibuprofen for chronic lower back
pain and occasional Benadryl to help her sleep at night.

Objective data: Her physical examination is within normal
limits.

Case Study 3:

HPI: Mr. George is a 72-year-old male who has lived alone
since his wife died approximately 1 year ago. He has lived in the same house
for 45 years. He is brought in by his son who is concerned that his father has
lost more than 35 pounds over the past year. Mr. George admits to not eating
well because “I don’t know how to cook for myself.”

PMH: He has been in good health with the exception of
hypertension, which is well controlled.

Social history: He spends most of his time watching sports
on television. He occasionally drinks one or two cans of beer when he is
watching TV. He does go to his son’s house to visit with his grandchildren about
once a week, and he says he enjoys that. He does not receive any social
services, he still drives but only in the daytime, and he does not participate
in any other leisure activities.

Objective data: His physical examination is normal. He
responds correctly to questions, although he appears to have a flat affect.

To prepare:

Review Chapters 6–8 of the Holroyd-Leduc and Reddy text.

Select one of the three case studies. Reflect on the way the
patient presented in the case study you selected, including whether the patient
might be presenting with dementia, delirium, or depression.

Think about how you would further evaluate the patient based
on medical history, current drug treatments, and the patient’s presentation.
Consider whether you would modify drug treatments, use additional assessment
tools, and/or refer the patient to a specialist.

Post on or before Day 3 an explanation of whether you
suspect the patient in the case study you selected is presenting with dementia,
delirium, or depression and why. Then, explain how you would further evaluate
the patient in the case study based on medical history, current drug
treatments, and the way the patient presented. Include whether you would modify
drug treatments, use additional assessment tools, and/or refer the patient to a
specialist.

Read a selection of your colleagues’ responses.

Respond on or before Day 6 to at least two of your colleagues
on two different days in one or more of the ways listed below. Respond to
colleagues who selected a different case study than you did.

Suggest additional tools for assessing the patients in the
case studies your colleagues’ selected.

Offer and support an alternative perspective based on your
own experience and additional research.

Validate an idea with your own experience and additional
literature search.

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entering your message. Then click on the Submit button to post your message.

Week 7 discussion

Nutrition and Hydration

Geriatric patients have many nutritional and hydration
concerns that impact their health and ability to acquire sufficient nutrients.
Advanced practice nurses evaluating these patients must be able to account for
all barriers that prevent elders from obtaining adequate nutrition, including
medical conditions, transportation, finances, physiologic changes, and
functional abilities. When evaluating patients, it is important to consider how
they eat, what their diet consists of, and whether they have any special
dietary needs that are not being met. Assessment tools, such as the Lawton
Instrumental Activities of Daily Living (IADL) Scale, are an integral part of
this evaluation process as they help providers identify potential obstacles for
patients. In this Discussion, you assess a patient at your current practicum
site and consider strategies for improving any nutrition or hydration issues.

To prepare:

Review this week’s media presentation, as well as Chapters
28 and 29 of the Flaherty and Resnick text.

Assess a patient using tools for inpatient and long-term
patient care, such as the Lawton IADL Scale. Note: You should coordinate this
opportunity with the Preceptor at your practicum site.

Consider whether nutrition and/or hydration might be
impacted by the patient’s functional abilities. Reflect on whether the patient
is able to go out and get food to eat, cook meals, safely use the stove, etc.

Consider the patient’s diet and whether they have any
special dietary needs due to medical conditions, such as congestive heart
failure, end-stage kidney disease, diabetes, oral health issues, etc. Reflect
on whether or not the patient is attempting to compensate for a medical issue
and thus creating a deficiency or excess in his or her diet.

Based on your patient assessment, think about strategies for
improving any nutrition issues that might have presented (e.g., nutritional
supplements, community resources such as Meals on Wheels, referral to a
nutritionist or dietician, etc.).

Post on or before Day 3 a description of the patient
assessment you performed using a tool for inpatient and long-term patient care,
such as the Lawton IADL Scale. Explain whether nutrition and/or hydration might
be impacted by the patient’s functional abilities. Then, describe the patient’s
diet and whether he or she has any special dietary needs due to medical
conditions. Address whether or not the patient is attempting to compensate for
a medical issue and thus creating a deficiency or excess in his or her diet.
Finally, explain strategies for improving any nutrition issues that might
present during the patient assessment.

Read a selection of your colleagues’ responses.

Respond on or before Day 6 to at least two of your
colleagues on two different days in one or more of the following ways:

Suggest additional strategies for improving nutrition issues
for your colleagues’ patients.

Offer and support an alternative perspective based on your
own experience and additional literature search.

Validate an idea with your own experience and additional
literature search.

Click on the Reply button below to reveal the textbox for
entering your message. Then click on the Submit button to post your message.

Week 8 discussion

Nursing Homes in Your Community and Neighboring Communities

Nursing homes have become a viable option for geriatric
patients who require routine care and need help performing basic activities of
daily living, with about 3.3 million patients residing in nursing homes in the
United States (Centers for Medicare & Medicaid Services, 2013). While
nursing homes provide care and services to patients, problems can arise
resulting in reduced quality of care and, in some cases, illness and morbidity.
The severe implications of pressure ulcers make them a major concern for elders
residing in nursing homes. The Centers for Medicare & Medicaid Services
(2013) estimate that 7.5% of nursing home residents have pressure ulcers and
about 82,000 patients develop them each year. In your role as the advanced
practice nurse, you must understand factors that contribute to the incidence of
pressure ulcers in order to improve patient outcomes. For this Discussion, you
examine the prevalence of pressure ulcers in nursing homes and develop
strategies for increasing awareness and reducing incidence.

To prepare:

Review Chapter 38 of the Flaherty and Resnick text and
Chapter 12 of the Holroyd-Leduc and Reddy text.

Select four nursing homes in your community and/or
neighboring communities. Research and locate reports on these nursing homes
through organizations such as Centers for Medicare & Medicaid Services.

Compare the four nursing homes you selected based on
reported cases of the development of new pressure ulcers.

Think about factors in the nursing home setting that
contribute to pressure ulcer issues, such as patient activity, nutrition, or
the number of staff available to care for patients.

Research guidelines for the prevention of pressure ulcers.
Think about how you might increase awareness among nursing home staff about the
incidence and consequences of pressure ulcers in patients.

Post on or before Day 3 a brief description of the four
nursing homes you selected from your community and/or neighboring communities.
Compare these four nursing homes based on the reported cases of new pressure
ulcers. Then, explain factors in the nursing home setting that might contribute
to incidence of pressure ulcer issues. Finally, based on guidelines for the
prevention of pressure ulcers, explain how you might increase awareness among
nursing home staff about the incidence and consequences of pressure ulcers in
patients.

Read a selection of your colleagues’ responses.

Respond on or before Day 6 to at least two of your
colleagues on two different days in one or more of the ways listed below.

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