geriatrics, long term care

8/2/2019 Geriatrics, Long Term Care

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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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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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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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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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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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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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Institutional Settings (continued)


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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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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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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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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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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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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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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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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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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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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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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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.

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