NURS6540 All Week Discussions latest 2018

NURS6540 All Week Discussions latest 2018

NURS6540 All Week Discussions latest 2018

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 3 and 8 of the 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.

By Day 3

Post 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. NURS6540 All Week Discussions latest 2018

By Day 6

Respond 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.

By Day 3

Post 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.

By Day 6

• Respond 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. NURS6540 All Week Discussions latest 2018

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. NURS6540 All Week Discussions latest 2018

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.

By Day 3

Post 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.

By Day 6

• Respond 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.

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.

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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.

By Day 5

Post 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.

By Day 7

• Respond 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. NURS6540 All Week Discussions latest 2018

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. NURS6540 All Week Discussions latest 2018

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.

By Day 3

Post 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.

By Day 6

• Respond 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.

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? NURS6540 All Week Discussions latest 2018

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. NURS6540 All Week Discussions latest 2018

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.

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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.

By Day 3

• Post 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.

By Day 6

• Respond 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.

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. NURS6540 All Week Discussions latest 2018

To prepare:

• Review this week’s media presentation, as well as 29 and 30 of the 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.).

By Day 3

• Post 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.

By Day 6

• Respond 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.

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 32 of the 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.

By Day 3

• Post 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. NURS6540 All Week Discussions latest 2018

By Day 6

• Respond 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 nursing homes 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.

Week 9 Discussion: Treating Patients in Specialized Areas of Care

When treating frail elder patients in specialized areas of care, there are various dynamics that might impact patient care plans. From questions about potential outcomes, benefits of treatment, and quality of life to factors such as personal values, families, culture, and religion, decision making can be difficult for patients and their families. As the advanced practice nurse, you must support them through this process.

For this Discussion, you examine the following case studies and consider how you might address the needs of the patients and their families. NURS6540 All Week Discussions latest 2018

Case Study 1

Mr. Wiggins is a 78-year-old African American male with chronic kidney disease, which requires dialysis. The etiology of his renal disease was multifactorial—long-standing uncontrolled HTN and DM nephropathy. He has been on hemodialysis for the past 10 years and has done relatively well. Four weeks ago, he had a major CVA and is minimally responsive.

His condition is not expected to change, and the family is having a difficult time with his recent health changes. Advanced directives were discussed with them, and his wife is a durable power of attorney for his health care. The wife hates to see her husband this way and understands this is not how he would want to go on, but their children and many of the family members (his brothers and sisters) think the patient will return to himself.

They want everything done in terms of life support measures—full code status. His family wanted a feeding tube placed, and he is now receiving 24-hour tube feedings. You are the NP caring for Mr. Wiggins. You have known and cared for him and his wife for several years. The wife pulls you aside, shares her dilemma, and asks you to make the decision regarding continuing medical care/support for her husband. How will you respond?

Case Study 2

Mrs. Adams is a 96-year-old Caucasian female who has recently been diagnosed with colon cancer. She was admitted to the hospitalist service through the ED with dehydration and rectal bleeding. The bleeding resolved, and she received 2 units of PRBs and fluid/electrolyte replacement. She is stable and ready to be discharged home.

Mrs. Adams is in remarkably good health, and other than arthritis and mild HTN, she has no significant medical or surgical history. She is able to carry out all of her essential daily living activities. She pays her own bills, is competent, and has good functional abilities. She was driving up until last year. Now, she has neighbor’s assist with weekly shopping and transportation to church. Her sensory, functional, and cogitative abilities were evaluated this admission and remain intact.

She has been offered palliative surgical intervention, but deferred all treatment. Her only son is in agreement with his mother’s decision. Her parents and husband are deceased. You have been asked to obtain advanced directives. What will your discharge treatment plan be for Mrs. Adams? NURS6540 All Week Discussions latest 2018

Case Study 3

Mr. Pierce is an 82-year-old East Indian male, recently widowed 6 months ago. He fractured his left hip 2 months ago attempting to climb his backyard fence to get his cat out of a tree. His children live internationally and have been taking turns caring for him. His eldest son brought him in through the ED last night because

Mr. Pierce started having shortness of breath and his lips turned blue. In addition, his son noticed his left leg was very swollen compared to the right. The ED nurse practitioner ordered a thin cut cat scan (CT) with pulmonary embolism (PE) protocol and deep vein thrombosis (DVT) scan. Mr. Pierce has a large DVT that is obstructing circulation and multiple pulmonary emboli. His condition is life threatening and he is only expected to live a few weeks.

He has a living will and advanced directives and has requested to be able to die in the comfort of his home. “I hate hospitals.” You have been consulted at the patient and family’s request because you are Mr. Pierce’s primary care provider. What additional services can be offered to ensure his care/comfort at home and to give him peace of mind regarding his estate?

To prepare:

• Select one of the three case studies. Reflect on the provided patient information.
• Think about potential outcomes for the patient in the case study you selected.
• Consider how care, treatment, and/or support might be facilitated for the patient. Reflect on how you might also address the needs of the family.

By Day 3

Post an explanation of potential outcomes of the patient in the case study you selected. Then, explain how care, treatment, and/or support may be facilitated for the patient. Include how you might address the needs of the patient’s family as well.

Read a selection of your colleagues’ responses.

By Day 6

• Respond 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.
• Offer alternative outcomes based on the case study and provided patient information.
• Share additional suggestions for the care, treatment, and/or support for the patients in the case studies your colleagues’ selected.
• Validate an idea with your own experience and additional literature search. NURS6540 All Week Discussions latest 2018

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Week 10 Discussion: Community Advocacy Agencies

Having received a diagnosis of Alzheimer’s and encountering the associated stigmas, Michael Ellenbogen encourages increased advocacy efforts for the geriatric population struggling with this disease. He says, “We did nothing wrong to get this disease, and we need to speak up to let our voice be heard…There are no excuses for not wanting to help.

The human cost factor is too high, and we are all accountable to do something” (Ellenbogen, 2012). As an advanced practice nurse caring for the geriatric population, it is important for you to join in advocacy efforts within your community whether it is in support of Alzheimer’s or another prevalent need such as abuse.

You should be aware of community agencies that advocate for the well-being and care of your local geriatric population, as these agencies often provide resources and assistance to the elderly in need. In your role of care, you are able to identify prevalent needs and work with patients, their families, and agencies to promote change and impact lives. NURS6540 All Week Discussions latest 2018

To prepare:

• Review this week’s media presentation, as well as the American Geriatric Society’s Public Policy and Advocacy website in the Learning Resources.
• Locate and research two agencies that advocate for the elderly in your community. Consider their current advocacy actions and/or campaigns.
• Reflect on your experiences and observations at your practicum site. Consider new advocacy actions you might suggest to the agencies you selected. Based on these advocacy actions, think about new policies that might improve the care of the population at your current practicum site.

By Day 3

Post a description of two agencies that advocate for the elderly in your community, including their current advocacy actions and/or campaigns. Then, explain new advocacy actions you might suggest to these agencies based on your experiences and observations at your practicum site. With these advocacy actions in mind, suggest at least one new policy that might improve the care of the population at your current practicum site.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days in different practicum settings than you. Explain issues within your own community that might impact the advocacy actions and policies suggested by your colleagues.

Week 11 Discussion: Discussing End-of-Life Care

There is a human tendency to postpone uncomfortable or unpleasant tasks.

—Nancy Kummer, geriatric patient

This human tendency to avoid the unpleasant makes end-of-life care and hospice decisions difficult for many patients to discuss with their families. Kummer is a former social worker who used to counsel patients with terminal illnesses, yet she avoided discussing her own end-of-life wishes with her children.

While many Americans, like Kummer, agree that these discussions need to take place, few have actually had these conversations with their families (Lazar, 2012). Although initiating conversations about end-of-life care and hospice might be difficult for patients, as an advanced practice nurse, facilitating these conversations is an integral part of your geriatric nursing practice.

For this Discussion, consider how you would facilitate care conversations with the patients and families in the following case studies:

Case Study 1

Mrs. Sloan, a 69-year-old widow, is about to enter the hospital for an elective cholecystectomy; she is being medically cleared by her primary care provider. During the discussion, she requests to be placed on a no code status during her hospitalization.

Mrs. Sloan claims that besides her gallbladder problem, her general health status is good. She wishes to have the surgery to avoid any further attacks, which have been very painful. She states, however, that if during surgery or her postoperative period, she undergoes a cardiac arrest, she would prefer not to be resuscitated.

She has read about the chances of successful resuscitation, and has determined that the risk of brain damage is too high. For this reason, she is requesting a no code status. NURS6540 All Week Discussions latest 2018

Case Study 2

Ms. Stearns is an 83-year-old nursing home resident with hypertension, coronary artery disease, arthritis, renal insufficiency, hearing impairment, and a previous history of stroke. She also has a foot deformity from childhood polio. She is disoriented at times. She has lived in the nursing home for 10 years and rarely leaves the chair beside her bed.

She has recently developed urinary incontinence, but has refused a bladder catheterization to determine postvoid residual urine or possible bladder infection. She does not have a diagnosis of dementia; however, current testing reveals that she performs poorly on a standardized mental status examination. She can, however, identify all the staff in the nursing home, and she can describe each patient who has been in the bed next to hers over the past 10 years.

When asked to explain why she does not want bladder catheterization, she gives several reasons. She states that the incontinence does not bother her, and that she has always been a very private person. She particularly dislikes and objects to any examination of her pelvic organs; in fact, she has never had a pelvic examination nor has she ever had sexual intercourse.

She realizes that she has a number of medical problems and that any one of them could worsen at any time. She states she is not willing to undergo any treatment for any of her current problems should they become worse.

Case Study 3

Mr. Marley, age 91, is admitted to the intensive care unit following a stroke. The stroke progressed from mild hemiparesis and difficulty speaking to complete unresponsiveness and an inability to swallow. His daughter feels certain, based on prior explicit conversations with her father, that he would not want to have any treatment that would prolong his life and leave him in a severely disabled state. Mr. Marley’s oldest son disagrees with his sister’s assessment of their father.

The son claims that their father still has a strong desire to live, and that he has been very active in his church until this stroke. Because Mr. Marley cannot swallow, he cannot be fed. The family is asked about insertion of a feeding tube. It is explained to the family that without food and fluids, their father will die fairly quickly. There are no existing advance directives or a designated health care decision maker noted for Mr. Marley. NURS6540 All Week Discussions latest 2018

To prepare:

Review Chapter 14 of the Holroyd-Leduc and Reddy text.

• Reflect on the role of the advanced practice nurse in facilitating the discussion of end-of-life care with patients and their families.
• Think about how you, as an advanced practice nurse, would approach a family who wants “everything” done for a patient with only a limited time to live.
• Consider when it is appropriate to involve hospice and how to approach patients and/or families who refuse hospice services.
• Select one of the three provided case studies related to the end-of-life care of the frail elderly. Reflect on potential patient outcomes and how you would facilitate the discussion of care with this patient’s family.

By Day 3

Post an explanation of the role of the advanced practice nurse in facilitating the discussion of end-of-life care with patients and their families. Explain how you would approach a family who wants “everything” done for a patient with only a limited time to live.

Then, explain when it is appropriate to involve hospice and how to approach patients and/or families who refuse hospice services. Finally, explain potential outcomes of the patient in the case study you selected and how you would facilitate the discussion of end-of-life care with this patient’s family.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days who selected different case studies than you. Based on the site of care, suggest strategies for establishing the role of advanced practice nurses in end-of-life discussions with patients. NURS6540 All Week Discussions latest 2018