NCMB314 LECTURE: Exam Week

12
BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
Bachelor of Science in Nursing 3YA
Professor: Caroline V. San Diego MAN, RN
Midterm Topics: Scope of Practice of Gerontological Nurse
• Concepts, Principles, History and Theories in the Care - They specialize in the nursing care and health needs of
of Older Adults older adults
• Ethico-Legal Considerations, Medications, and - They plan, manage and implement health care to meet
Ethical Principles in the Care of Older Adult those needs & evaluate the effectiveness of such care
• Long-Term Care Facility, Palliative, Ethical Dilemmas - The primary challenge
• Communicating with Older Adults • To identify & use the strengths of older adults and
• Guidelines for effective documentation • To assists them in maximizing their independence
- They must actively involve older adults & family members;
CORE ELEMENTS OF GERONTOLOGICAL NURSING in decision making process (w/c has a great impact on the
PRACTICE everyday quality of life of the pt.)
- With the formalization and growth of the gerontological Roles of the Gerontological Nurse
nursing specialty, nurses and nursing organizations have • Provider of care
developed informal and formal guidelines for clinical • Teacher/Educator
practice. Some of these core elements include evidence- • Manager
based practice and standards and principles of • Advocate
gerontological nursing. • Research Consumer
Standards of Clinical Gerontological Nursing Care
Evidence-Based Practice • STANDARD I. Assessment
- There was a time when nursing care was guided more by • STANDARD II. Diagnosis
trial and error than sound research and knowledge. • STANDARD III. Outcome Identification
Fortunately, that has changed, and nursing now follows a • STANDARD IV. Planning
systematic approach that uses existing research for • STANDARD V. Implementation
clinical decision making-a process known as evidence-
• STANDARD VI. Evaluation
based practice. Testing, evaluating, and using findings in
the nursing care of older adults is of such importance that
Core Competencies
it is among the ANA Standards of Professional
- Provide a foundation of added knowledge and skills
Gerontological Nursing Performance.
necessary for the nurse to implement in daily practice.
- Evidence-based practice relies on the syntehesis and
- This was developed by the AACN and the John A Hartford
analysis of available information from research. Among
Foundation Institute for Geriatric Nursing “OLDER
the more popular ways to report this information are the
ADULTS: Recommended Baccalaureate Competencies
meta-analysis and cost-analysis (Agency for Health Care
and Curricular Guidelines for Geriatric Nursing Care” –
Research and Quality, 2008). Meta-Analysis is a process
This serves as guides to nursing professors to prepare
of analyzing and compiling the results of published
students to be competent to provide excellent care to
research studies on a specific topic. This process
Older adults
combines the results of many small studies to allow more
- Core Competencies
significant conclusions to be made. With cost-analysis
• Critical Thinking
reporting, cost-related data are gathered on outcomes to
make comparisons. Performance also can be compared • Communication
with best practices or industry averages through a process • Assessment
of benchmarking. • Technical skills
American Nurses Association (ANA) - Role Development
- Published a Statement on the Scope of Gerontological • Provider of care
Nursing Practice in 1970 • Designer/manager/coordinator of care
- Defines nature and scope of gerontological nursing • Member of a profession
- Purpose: - Core Knowledge
• Health promotion • Health promotion, risk reduction, & disease
• Healthy maintenance prevention
• Disease prevention • Illness and disease management
• Self-care • Information & health care technologies
• Ethics
• Human diversity , Global health care
• Health care system & policy

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 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
Competencies and Curricular Guidelines for Geriatric
Nursing Care
• Recognize one’s own & others’ attitudes, values, &
expectations about aging & their impact on care of older
adults & their families.
• Adopt the concept of individualized care as the standard
of practice with older adults.
• Communicate effectively, respectfully & compassionately
with older adults & their families.
• Recognize that sensation & perception in older adults are
mediated by functional, physical, cognitive, psychological,
& social changes common to old age.
• Incorporate into daily practice valid and reliable tool to
assess the functional, physical, cognitive, psychological,
social & spiritual status of older adults.
• Assess older adults’ living environment with special
awareness of the functional, physical, cognitive,
psychological, & social changes common to old age.
• Analyze the effectiveness of community resources in
assisting older adults & their families to retain personal
goals, maximize function, maintain independence, & live
in the least restrictive environment.
• Assess family’s knowledge of skills necessary to deliver
care to older adults.
• Adapt technical skills to meet the functional, physical,
cognitive, psychological, social and endurance capacities
of older adults.
• Individualize care & prevent morbidity & mortality
associated with the use of physical & chemical restraints
in older adults.
• Prevent or reduce common risk factors that contribute to
functional decline, impaired quality of life & excess
disability in older adults.
• Establish & follow standards of care to recognize & report
elder mistreatment.
• Apply evidence-based standards to screen, immunize &
promote healthy activities in older adults.
• Recognize & manage geriatric syndromes common to
older adults.
• Recognize the complex interaction of acute & chronic co-
morbid conditions common to older adults.
• Use technology to enhance older adults’ function,
independence & safety.
• Facilitate communication as older adults transition across
& between home, hospital, & nursing home, with a
particular focus on the use of technology.
• Assists older adults, families & caregivers to understand &
balance “everyday” autonomy & safety decisions.
• Apply ethical & legal principles to the complex issues that
arise in care of older adults.
• Appreciate the influence of attitudes, roles, language,
culture, race, religion, gender, & lifestyle on how families
& assistive personnel provide long-term care to older
adults.
• Evaluate differing international models of geriatric care.
• Analyze the impact of an aging society on the health care
system.
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• Evaluate the influence of payer system on access,
availability & affordability of health care for older adults.
• Contrasts the opportunities & constraints of a supportive
living arrangement on the function & independence of
older adults & on their families.
• Recognize the benefits of interdisciplinary team
participation in the care of older adults.
• Evaluate the utility of the complimentary & integrative
health care practices on health promotion & symptom
management for older adults.
• Facilitate older adult’s active participation in all aspects
of their own health care.
• Involve, educate & when appropriate, supervise family,
friends & assistive personnel in implementing best
practices for older adults.
• Ensure quality of care commensurate with older adults’
vulnerability and frequency & intensity of care needs.
• Promote the desirability of quality end-of-life care for
older adults, including pain & symptom management, as
essential, desirable & integral components of nursing
practice.
Principles of Gerontological Nursing Practice
• Aging is a natural process common to all living organisms.
Various factors influence the aging process.
• Unique data and knowledge are used in applying the
nursing process to the older population.
• Older adults share similar self-care and human needs in
all other human beings.
• Gerontological nursing strives to help older adults achieve
wholeness by reaching optimum levels of physical,
psychological, social, and spiritual health.
Terminologies:
• Core Competencies – the essential skills and knowledge
needed to provide quality care to older adults
• Health promotion – activities aimed at improving or
enhancing health
• Primary prevention – activities designed to completely
prevent a disease from occurring, such as immunization
against pneumonia or influenza.
• Secondary prevention – efforts directed toward early
detection and management of disease, such as the use of
colonoscopy to detect small, cancerous polyps.
• Standard – desired, evidence-based expectations of care
that serve as a model against which practice can be
judged
• Tertiary prevention – efforts used to manage clinical
diseases in order to prevent them from progressing or to
avoid complications of the disease.
• Evidence-based practices: using research and scientific
information to guide actions
• Gerontological nursing: nursing practice that promotes
wellness and highest quality of life for aging individuals
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER
ADULT / MEDICATIONS/ ETHICAL PRINCIPLES
Ethics of Care
- include compassion, equity, fairness, dignity,
confidentiality, and mindfulness of a person’s autonomy
within the realm of the person’s abilities and mental
capacity.
1) Advocacy – refers to loyalty and a championing of the
needs and interest of others, to educate and informed
the patients about their rights and access benefits
entitled for them.
2) Autonomy- is the concept that each person has a
right to make independent choices and decisions.
3) Beneficence / Nonmaleficence- These concepts of
do good (beneficence) and do no harm
(nonmaleficence) are integral to health care.
4) Confidentiality – emphasizes respect for human
dignity that is demonstrated in daily work.
5) Fidelity – refers to keeping promises or being true to
another, being faithful to commitments and
responsibilities.
6) Fiduciary Responsibility – refers to using both fiscal
reserves and caregiving resources wisely, potentially
requiring a cost-benefit analysis to facilitate decision
making.
7) Justice – refers to fairness of an act situation
8) Quality and sanctity of Life – quality of life is a
perception based on personal values and beliefs,
sanctity of life referring to the value of life and the right
to live.
9) Reciprocity – is a feature of integrity concerned with
the ability to be true to one’s self while respecting and
supporting the values and views of another.
10) Veracity – means truthfulness and refers to telling the
truth, or at the least, not misleading or deceiving
patients or their families.
Issues to be Considered
• Issues on Conflict of interest
• Issues on Confidentiality
• Issues on decision-making capacity
Issues on Conflict of interest
1) Actual Conflict of Interest issues
- between family members and caregivers represent
the elderly or assist them in decision-making
- These include conflicts:
• Between spouses and the elder’s wishes and
interest;
• Between family members and the elder’s wishes
and interest;
• Between a guardian, conservator or other lawfully
designated agent and the elder’s wishes and
interests;
• Between a caregiver’s business interests and the
elder’s interests. Well-being and quality of life.
2) Perceived Conflicts of Interest
- which include those which are not actual conflicts in
the course of care but may later become conflicts
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when the elder patient’s interest diverge from those
who provide the care.
Issues on Confidentiality
- In caring for an elderly patient, invariably, there is
disclosure made by the family and relatives regarding
information that may otherwise be personal and
confidentiality to the patient alone.
Issues on Decision- Making Capacity
- Many times, the older patient’s decision-making capacity
(also referred to as “competence”) may be required for
certain decisions.
Legal Risks in Gerontological Nursing
• Malpractice
• Confidentiality
• Patient consent
• Patient competency
• Staff supervision
• Medications
• Restraints
• Telephone orders
• Do not resuscitate orders
• Advance directives and issues related to death and dying
• Elder abuse
Benefits and Previleges of “Senior Citizen”
• Republic act No. 344 or the Accessibility Law of 1982 –
provides for the minimum requirements and standards to
make buildings, facilities, and utilities for public use
accessible to persons with disability, including older
persons who are confined to wheelchair and those who
have difficulty in walking or climbing stairs, among others.
• RA 7432 – known as “an act to maximize the contribution
of senior citizens to nation building, grant benefits and
special privileges and for other purposes”.
• Republic Act No. 7876 or “An Act Establishing a senior
Citizens Center in all Cities and Municipalities of the
Philippines, and Appropriating Funds Therefore” –
provides for the establishment of senior Citizens Centers
to cater to older persons’ socialization and interaction
needs as well as to serve as a venue for the conduct of
other meaningful activities.
• Republic Act No. 8425 – provides for the
institutionalization and enhancement of the social reform
agenda by creating the National Anti-Poverty commission
(NAPC). Through its multidimensional and cross- sectoral
approach, NAPC provides a mechanism for older persons
to participate in policy formulation and decision-making
on matters concerning poverty alleviation.
• Republic Act No. 9994. “Expanded Seniors Citizen Act
of 2010”- an act granting additional benefits and
privileges to senior citizens, further amending.
• Republic Act No. 7432 and otherwise known as “an act
to maximize the contribution of senior citizens to nation
building, grant benefits and special privileges and for
other purposes.
• Republic Act No. 10155, “ The General Appropriations
Act of 2012” – under Section 28 mandates that all
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
government agencies and instrumentalities should
allocate one percent of their total agency budget to
programs and projects for older persons and persons with
disability.
• Republic Act No. 10645, An Act Providing For the
Mandatory Philhealth Coverage for All Senior Citizens”,
Amending for the purpose, Republic act No. 7432, as
amended by Republic Act No. 9994 by removing the
qualification that a senior citizen has to be indigent before
being covered by PhilHealth
• Republic Act No. 10868, “Centenarians Act of 2016”,
An Act Honoring and Granting Additional Benefits and
Privileges to a FILIPINO CENTENARIANS. All Filipinos
who have turned centenarian in the current fiscal year
shall be awarded a plaque of recognition and a cash
incentive by their respective city or municipal
governments in appropriate ceremonies in addition to the
LETTER of FELICITATION and centenarian gift of P
100,000.00. Aside from DSWD, other agencies involved in
the implementation of the law’s provisions are
Department of the Interior and Local Government (DILG),
Department of Health (DOH), and Commission on
Filipinos Overseas (CFO).
• Presidential Proclamation No. 470, Series of 1994,
declares the first week of OCTOCER of every year as
“Elderly Filipino Week.”
• Presidential Proclamation No. 1048, Series of 1999,
declaring a “Nationwide Observance in the Philippines of
the International Year of Older Persons”.
• Executive Order No. 105, series of 2003, approved and
directed the implementation of the program providing for
group homes and foster homes for neglected, abandoned,
abused, detached, and poor older persons and persons
with disabilities.
• The Philippine Plan of Action for senior Citizens (2011-
2016). This plan aims to ensure giving priority to
community-based approaches which are gender-
responsive, with effective leadership and meaningful
participation of senior citizens in decision-making
processes, both in the context of family and community.
• RA 9257 It shall train community-based health workers
among senior citizens and health personnel to specialize
in the geriatric care and health problems of senior citizens.
Pharmacology and Older Adult
- Older person are at a greater risk for adverse drug events
than younger persons because of differences in the body's
utilization of drugs.
- Persons 65 and older are prescribed the highest
proportion of medication in relation to their percentage.
- More appropriate predictors of medications response
include general state of health, number and types of other
medications taken liver and renal function, presence of
co-morbidities or other diagnosed diseases.
Changes with Aging
• Decrease in body water (as much as 15%) and an increase
in body fat.
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• Increased concentration of water-soluble drugs (e.g.
Alcohol)
• More prolonged effects of fat-soluble drugs.
• Decreased hepatic blood flow - results in increased
toxicity= Increased SGPT, Increased PT, PTT
• Changes in pharmacodynamics in the older person may
be caused by decreases in the number of receptors and
receptor binding.
• Decreased serum albumin level
- Altered binding capacity
- Increased serum level of the free or unbound
proportion of protein- bound drugs
- Toxic level of highly bound drugs
Inappropriate medications administered to older persons
include:
• Prescriptions for long-acting benzodiazepines, persantine
• Long-term use of drugs that are to be used for short-term
use only (e.g., histamine blockers, short-acting
benzodiazepines, oral antibiotics)
• Decreased hepatic blood flow results in increased
toxicity= Increased SGPT, Increased PT, PTT
• Results in increased toxicity when older persons take
usual doses of "first-pass effect" drugs because a smaller
portion of these drug concentration would be detoxified
immediately by the liver.
Decreases in serum albumin level
• Leads to altered binding capacity
• May cause increased serum levels of the "free" or
unbound proportion of protein-bound drugs.
• May result in toxic levels of highly bound drugs because
more unbound drug is available to produce its effects
• The kidneys excrete most drugs – Individuals vary in
degree of decline of renal function
Predictors of Medication Response Include:
• General state of health
• Number and types of other medications taken
• Liver (sgpt) and renal function (creatinine)
• Presence of comorbidities or other diagnosed diseases
Medication error:
- It may be related to: Prescribing, Dispensing,
Administering or Monitoring of drug.
- Root cause: Attributed to human knowledge based
deficiencies and a lack of sophisticated systems to
support and monitoring drug therapy
2 Important Distinctions in Medication Error Language:
1) Adverse Drug Reaction (ADR) – any noxious, unintended,
and undesired effects of a drug which occurs at doses in
human for prophylaxis, diagnosis or therapy.
• Difficulties in the activities of daily living
• Cognitive changes
• Falls
• Anorexia, nausea
• Weight changes
2) Adverse Drug Event (ADE) – any injury that results in
medications used, and this includes both ADRs and
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
medication errors that lead to an ADR. Note: The use of
too many wrong types of medications increases the risks
of both of an ADE and non-adherence)
Factors that contribute to increased risk of ADE
1) Pharmacokinetic Changes – what the body does to the
drug. These include changes in:
• Drug Absorption – Age-related changes in drug
absorption do not usually contribute to a significantly
altered drug response and are generally thought to
have less significant impact on pharmacokinetics
• Drug Distribution or Protein-binding - Drug distribution
into the peripheral circulation and tissues is altered
as a function of age
- Drug distribution into the peripheral circulation
and tissues is altered as a function of age.
- A decrease in plasma albumin levels with age
may result in decreased binding of drugs that or
mainly bound to serum albumin.
- A decrease in total body water and intracellular
water volumes may lead to an increased serum
concentration of water-soluble drugs such as
lithium or alcohol.
- An increase in body fat may increase the
distribution of fat-soluble medications such as
benzodiazepine into fatty tissue, resulting in
prolonged half-lives and drug accumulation
- Also relies on the bioavailability of the drug
• Hepatic Metabolism
- Age-related changes in hepatic drug metabolism
are not easily measured.
- Biotransformation occurs in all body tissues but
primarily in the liver, where enzymatic activity
alters and detoxifies the drug to prepare it for
excretion.
• Renal Excretion
- The most important pharmacokinetic parameter
that changes with age. Although the change in
renal function is extremely variable, the majority
of older adults have a decline kidney function.
This may require a decreased dose or extension of
the dosing interval for certain drugs.
- Serum creatinine may be used as indirect
estimate of renal function by calculating
creatinine clearance.
- Creatinine clearance (ml/min) = 140 – Age (in
years) x Weight in Kilograms 72 x Serum
creatinine (mg/dl)
- For women, multiply final result by 0.85
- Creatinine – Male: 0.7 – 1.7 mg/dl ; female : 0.4 –
1.4 mg/dl .
- Creatinine clearance is an estimate of Glomerular
Filtration (GFR) and decreases with age.
- Blood Urea Nitrogen (BUN) – 7-23 mg/dl. Used as
the gross measure of glomerular function and the
production and excretion of urea.
- Alkaline Phosphatase – 34-122 u/l ; Indicator of
liver disease.
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2) Pharmacodynamic Changes – what then drug does to
the body? Aging may result in different responses for older
adults to the same drug concentrations at the site of
action compared with those observed in younger adult.
Changes in Pharmacodynamics in older person may be
caused by:
• Altered number of receptors or affinity
• Decreases in receptor binding
• Altered cellular responses to the drug-receptor
interaction
• Organ pathologic condition
• Altered homeostatic mechanisms
3) Drug-Food Interactions – the presence or absence of any
food that may reduce or increase the bioavailability of a
medication, leading to unanticipated effects.
• Theophylline and caffeine – increased potential for
toxicity
• Levodopa and clonidine – decreased antiparkinsonian
effect
4) Drug-Drug Interaction - an interaction between one drug
and another can result from altered harmacokinetics or
pharmacodynamics. it is largely thought that alterations in
hepatic metabolism are specifically responsible for drug-
drug interaction.
• Warfarin and aspirin- increased risk for bleeding.
5) Drug-Disease Interactions - Certain disease states may
be exacerbated by specific drug therapies, and these
drugs may be contraindicated in patients with a coexisting
underlying disease.
• Aspirin, NSAIDs and Atrophic gastritis – GI
hemorrhage
Polypharmacy
- Prescription, administration, or use of more medications
than are clinically indicated in a given patient.
- Multiple medications increase the chance of
• Drug-drug interaction
• ADEs and ADRs
• Errors of dosing
- Prevention of Polypharmacy includes
• Use of the same pharmacy to fill all prescriptions
• Notification to all prescribing clinicians of drugs used,
including:
• Prescribed medications
• Herbal remedies
• OTC medications
• Dietary supplements
• Vitamins
Problems with medication use in the nursing facility have
prompted federal legislation:
Omnibus Budget Reconciliation Act (OBRA) 1987
1) Legislated the appropriate use of medications in
institutionalized older persons
• Use of chemical restraint
• Use of unnecessary drugs
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
• Antipsychotic drugs should not be used unless
necessary to treat a specific condition that is
diagnosed and documented in the clinical record.
2) Beers Criteria
• Commonly used consensus criteria related to
inappropriate medications.
• Developed in 1997, and adopted in 1999 by the
centers of medicare and medical services for the
regulation of medications in nursing homes.
• Inappropriate medications administered to older
persons include:
- Prescriptions for long-acting benzodiazepines,
persantine, propoxyphene
- Long-term use of drugs that are to be used for
short-term use only. (e.g., histamine blockers,
short-acting benzodiazepines, oral antibiotics)
- High doses of drugs prescribed above dosage
limitations (iron supplements, histamine blockers,
antipsychotic agents)
Commonly used medications
Anxiolytics and Hypnotics
- Anxiety can be a significant problem in older persons and
is often associated with depression & dementia.
- According to the Beer's list, benzodiazepines with long
half-lives should be avoided because of the likelihood of
accumulation of the patient drug and its active metabolite,
resulting in increase toxicity
- Daily use of both long and short-term acting
benzodiazepines
• Should be limited to less than 4 continuous months
• Should be limited unless an attempt at gradual dose
reduction is unsuccessful
• Dose reductions should be considered after 4 months
Antidepressants
- All antidepressants are generally equally effective and
typically take effect in 2 to 4 weeks
- Overall, tricyclic antidepressants should be avoided in the
older patient because of their anticholinergic and sedative
side effects profile
- The newer SSRIs are often considered the first choice for
antidepressants in older adults because of their lack of
TCA side effects
Antipsychotics
- Should be prescribed only when valid and clear
documentation of need exists, since many side effects
occur with use of these agents.
- Appropriate indications for antipsychotic prescription
include schizophrenia, paranoid states, and symptoms of
psychosis such as hallucinations and delusions.
- 3 D's that may justify antipsychotic use:
• Danger to the resident or others
• Distress for the resident
• Dysfunction of the resident, including interference
with basic nursing care
- Conditions inappropriate Antipsychotic drug use:
• Wandering
• Poor self-care
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• Restlessness
• Impaired memory
• Anxiety
• Depression
• Insomnia
• Unsociability
• Indifference to surroundings
• Fidgeting
• Nervousness
• Uncooperativeness
• Agitated behavior when not a danger to self or others.
- Residents who use antipsychotic drugs should receive
• Gradual dose reductions
• Drug holidays
• Behavioral programming unless clinically
contraindicated
- PRN dose of Neuroleptics
• Are not to be used more than twice in a 7-day period
without Further assessment unless for the purpose of
titrating dosage for optimal response unless for
management of unexpected behaviors otherwise
unmanageable.
Cardiovascular Medications
- The main concerns with the use of cardiovascular
medications in older adults are an increased risk of
orthostatic hypotension and dehydration, especially with
volume-depleting agents and vasodilators.
Antimicrobials
- Dosing of antibiotics may need to be altered in older
clients because of reduced renal elimination
Nonprescription Agents
- FDAs division of over-the-counter drug evaluation
considers three main criteria when reviewing an request to
switch a prescription product to OTC status:
• A record of established safety data for the
prescription product is necessary
• The drug's expected use should be appropriate for
OTC treatment
• The drug should lack undesirable properties and not
require special precautions when used without
physician oversight
Non-Adherence (non-compliance)
- Risk factors:
• Living alone without social support.
• Visual or auditory impairments.
• Increasing use of alcohol.
• Socioeconomic factors.
• Unpalatable bulk powders or large tablets.
Nursing Management for Improving Clients Adherence
• If knowledge deficits are a problem, provide verbal
education, reinforced with written instructions and allow
time for client’s feedback.
• Encourage a client who “pharmacy shops” to have
prescriptions filled at the same pharmacy each time.
• Provide and assist remembering to take medications.
• Reduce the impact of drug side effects.
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
• Give adequate intake of fiber and fluid to reduce
constipation.
• Diuretics can be scheduled in the morning to reduce
interruptions of activities and sleep.
• Use of Isotonic liquids or sugar-free lozenges can help
with dry mouth.
Role of the Nurse
• Being aware of the routes of eliminations of medications
and the implication of aging on these routes.
• Being aware of the effects of aging on the typical signs and
symptoms of medication toxicity.
• Maintaining knowledge of the signs of medication toxicity
in the older adult
• Drawing random, peak and trough medication levels
correctly
• Knowing when to notify the prescriber of abnormal results.
Ethical Principles
- Omission or commission of an act that departs from
acceptable and reasonable standards, which can take
several forms
• Malfeasance: committing an unlawful or improper act.
• Misfeasance: performing an act improperly
• Nonfeasance: failure to take proper action
• Malpractice: failure to abide by the standards of one’s
profession
• Criminal negligence: disregard to protection the safety
of another person
Terminologies
• Conflict of Interest - a situation in which a person is in a
position to derive personal benefit from actions or
decisions made in their official capacity.
• Confidentiality - It means that professionals shouldn't
share personal details about someone with others, unless
that person has said they can or it's absolutely necessary.
• Depression - a mood disorder that causes a persistent
feeling of sadness and loss of interest and can interfere
with your daily functioning.
• Ethics – moral principles that govern a person's behavior
or the conducting of an activity.
• Consent – granting of permission to have an action taken
or procedure performed
• Malpractice – deviation from standard of care
• Negligence – failure to conform to the standard of care
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LONG-TERM CARE FACILITY, PALLIATIVE, ETHICAL
DILEMMAS
Long Term Care
- The long- term care facility is becoming a complex and
dynamic clinical setting for nursing practice. Increasingly,
such facilities are caring for a more medically complex
population than ever before; many nursing homes are
establishing subacute care units that provide ventilator
care, hyperalimentations, and other services that were
confined to hospital settings. Consumers are well
informed of the standards of good care and quality living
environments, giving them higher expectations of
providers than previously. Also, for many nurses who have
become frustrated with the caregiving limitations of
abbreviated hospital stays and fragmented care, such
facilities offer an opportunity to establish long-term
relationships and practice nursing’s healing arts.
- Although the number of facilities providing long-term care
has declined since the implementation of tougher
standards, the number of residents who are served in
long-term care facilities has grown along with the growth
of the older people entering their senior years, a majority
will need some type of facility-based or community long-
term care, and about half of all older women and one third
of all older men will spend some time in a long –term care
facility during their lives.
- Long-term care is a variety of services which help meet
both the medical and nonmedical needs of people with a
chronic illness or disability who cannot care for
themselves for long periods.
Nursing Homes Standards
- “must provide services and activities to attain or maintain
the highest practicable physical, mental, and
psychosocial well-being of each resident in accordance
with a written plan of care.”
- Regulations related to nursing homes:
• Resident rights
• Admission, transfer, and discharge rights
• Resident behavior and facility practices
• Quality of life
• Nursing services
• Dietary services
• Physician services
• Specialized rehabilitation services
• Dental services
• Pharmacy services
• Infection control
• Physical environment , Administration
Nursing Home Residents
- Care homes, also called residential care facilities or group
homes, are small private facilities, usually with 20 or
fewer residents.
- Factors to consider when selecting a nursing home:
• Cost
• Philosophy of care
• Administration
• Special services
• Staff
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
• Residents
• Physical facility
• Meals
• Activities
• Care
• Amily involvement
• Spiritual needs
Assisted Living Communities
- Designed for older adults who are able to remain
independent and active, but need a helping hand.
- Major responsibilities of gerontological nurses in long-
term care facilities:
• Assist residents and their families in the selection of
and adjustment to the facility
• Assess and develop an individualized care plan based
on assessment data
• Monitor residents’ health status
• Recommend and use rehabilitative and restorative
care techniques when possible
• Evaluate the effectiveness and appropriateness of
care.
• Identify changes in residents’ conditions and take
appropriate action.
• Communicate and coordinate care with the
interdisciplinary team.
• Protect and advocate for residents’ right
• Promote a high quality of life for residents.
• Assure residents’ preferences and choices are
honored.
• Ensure and promote the competency of nursing staff.
Hierarchy of Nursing Home Resident’s Needs
• Palliative Care - is an interdisciplinary medical caregiving
approach aimed at optimizing quality of life and mitigating
suffering among people with serious, complex illness.
Palliative care is the active total care of clients whose
diseases is not responsive to curative treatment. Control
of pain, of other symptoms, and of psychological, social,
and spiritual problems is paramount. The goal of palliative
care is achievement of the best possible quality of life for
clients and family. It affirms life and regards dying as a
normal process.
• HOSPICE - a way of caring for terminally ill individual and
their families. Although most hospice care is provided in
J.A.K.E 8 of 16
the home, these services are required to be provided in
nursing home settings also. The first hospice program was
St. Christophers’ Hospice in London. In the United States,
the first hospice began at Hospice, Inc. in New Haven,
Connecticut, in 1974. The National Hospice Organization
has developed standards for hospice care to guide local
hospice programs; however, individuality and autonomy of
each program are encouraged. Hospice care aids in
adding quality and meaning into the remaining period of
life. The care involves interdisciplinary efforts to address
physical, emotional, and spiritual needs, including:
• pain relief
• symptom control
• coordinated home care and institutional care
• bereavement follow-up and counseling
Death and Dying
Loss
- An actual or potential situation in which something that is
valued is changed, no longer available or gone.
- Parting with an object, person, belief or relationship that
one values.
- Loss of body image, significant other, a sense of well-
being, a job, personal possessions, beliefs, a sense of self.
etc.
- Types of Loss:
1) Personal loss - Any significant loss of someone or
something that can no longer be seen or felt, heard,
known or experienced & that requires individual
adaptation through the grieving process.
2) Perceived loss - Loss that is less tangible & uniquely
defined by the grieving client (loss of confidence,
prestige). Experienced by one person but cannot be
verified by others.
3) Maturational loss - Change in developmental process
that is normally expected during a lifetime. Loss that
occur on the process of normal development.
4) Situational loss - Loss of a person, thing or quality
resulting from a change in a life situation, including
changes related to illness, body image, environment
and death. Any sudden, unexpected and definable
event that is not predictable.
5) Actual loss - Can be identified by others & can arise
either in response to or in anticipation of a situation.
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
Any loss of a person or object that can no longer be
felt, heard, known, or experienced by the individual.
Grief
- The total response to the emotional experience related to
loss which is usually resolved within 6 months to 2 years.
- Sorrow manifested in thoughts, feelings, & behaviors
occurring as a response to an actual or perceived loss.
- Permits individual to cope with the loss gradually & to
accept it as part of reality; a social process best shared &
carried out with assistance of others.
- May be experienced as a mental (anger, guilt, anxiety,
sadness & despair); physical (sleeping problems,
difficulties in swallowing, vomiting, fatigue, headaches,
dizziness, fainting, blurred vision, skin rashes, excessive
sweating, menstrual disturbance, palpitations, chest pain,
dyspnea, changes in appetite, physical problems, weight
loss, or illness); social (feelings about taking care of
others in the family, seeing family or friends, or returning
to work, or emotional reaction (depression, etc.)
- Types of Grief
1) Abbreviated grief - Grief which is brief but genuinely
felt; lost may not have been sufficiently important to
the grieving person or may have been replaced
immediately by another, equally esteemed object.
2) Anticipatory grief - Process of accomplishing part of
the grief work before an actual loss; grief response in
which the person begins grieving process before an
actual loss.
3) Dysfunctional grief - Occurs when there is prolonged
emotional instability, withdrawal from usual task or
activities that previously gave pleasure & lack of
progression from one level to successful coping with
the loss. Extended grief, unsuccessful use of
intellectual and emotional responses by which
individuals attempt to work through the process of
modification.
- Dysfunctional Grief may be:
1) Unresolved Grief - extended in length and severity,
bereaved may also have difficulty expressing the grief,
may deny the loss or may grief beyond expected time;
severe chronic grief reaction in which the person does
not complete the resolution stage of the grieving
process within a reasonable time.
2) Inhibited Grief – many of normal symptoms of grief are
suppressed and other effects, including somatic are
experienced instead.
- Grieving process - Sequence of affective, cognitive &
physiological states through which the person responds to
and finally accepts an irretrievable loss.
- Bereavement - The subjective response experienced by
the surviving loved ones after the death of a person with
whom they have shared a significant relationship.
Experience alterations in libido, concentration, patterns of
eating, sleeping, activity and communication.
Concepts which help the Nurse to Plan for Interventions:
1) Mourning - The behavioral process through which grief is
eventually resolved or altered. Process by which people
J.A.K.E 9 of 16
adapt to a loss which is influenced by cultural, customs,
rituals, and society’s rules for coping with loss.
2) Hope - Characterized by a confident, yet uncertain
expectation of achieving a goal.
3) Closure - The point at which the loss has been resolved
and the grieving individual can move on with life without
focusing on the loss.
Sources of Loss
1) Loss of Aspect of Self - Any change the person perceives
as negative in the way the person relates to the
environment is loss of self.
2) External Object - Loss of inanimate object that has
importance to the person (ex. Jewelry, money, etc…)
3) Accustomed Environment - Separation from an
environment and people who provide security.
4) Loved Ones - Loss of valued person or loved ones through
illness, separation, divorce, broken relationship, moving,
running away, promotion at work, or death.
5) Loss of Life - Physical death, brain death, ability to reason.
Concern is not about death itself but about pain and loss
of control, fear of separation, abandonment, loneliness or
mutilation.
Signs of Impending Death
Loss of Muscle Tone
• Relaxation of the facial muscles (jaw may sag)
• Difficulty speaking
• Difficulty swallowing & gradual loss of the gag reflex.
• Decreased activity of the GIT, with subsequent nausea,
accumulation of flatus, abdominal distention & retention
of feces.
• Possible urinary & rectal incontinence due to decreased
sphincter control
• Diminished body movement
Slowing of the Circulation
• Diminished sensation
• Mottling & cyanosis of the extremities
• Cold skin, first in the feet and later in the hands, ears and
nose (however the client may feel warn due to elevated
temperature)
Changes in Vital Signs
• Decelerated and weaker pulse
• Decreased BP
• Rapid shallow, irregular, or abnormally slow respirations;
Cheyne strokes respirations; noisy breathing, referred to
as death rattle due to collecting of mucus in the throat;
mouth breathing, which leads to dry oral mucus
membranes.
Sensory Impairment
• Blurred vision
• Impaired sense of taste & smell (hearing is the last sense
to disappear)
Clinical Signs of Death
- Cessation of the apical pulse, respirations and blood
pressure.
• Total lack of response to external stimuli.
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
• No muscular movement, especially breathing.
• No reflexes.
• Flat encephalogram for 24 hours.
- Cerebral Death - Occurs when the higher brain center,
the cerebral cortex, is irreversibly destroyed. It is believed
that the cerebral cortex, which holds the capacity for
thought, voluntary action & movement, is the individual.
Body Changes
1) Rigor Mortis
- Stiffening of the body that occurs about 2 to 4 hours
after death due to lack of Adenosine Triphosphate
(ATP),which is not synthesized because of a lack of
glycogen in the body.
- Starts in the involuntary muscles (heart,bladder, etc.)
then progresses to head, neck, trunk and finally
reaches the extremities.
- Leaves the body about 96 hours after death.
2) Algor Mortis
- Gradual decrease of the body’s temperature after
death.
- When blood circulation terminates and the
hypothalamus ceases to function, body temperature
falls about 1 degree Celsius per hour until it reaches
room temperature.
3) Livor Mortis
- Bluish discoloration of the skin after death.
After blood circulation has ceased, skin becomes
discolored.
The RBC breakdown, releasing hemoglobin, which
discolors the surrounding tissues.
4) Embalming
- Injection of chemicals in the body to destroy the
bacteria.
- Tissues after death become soft & eventually liquefied
by bacterial fermentation.
- The hotter the temperature, the more rapid the
change, therefore, bodies are often stored in cool
places to delay the process.
Stages of Death and Dying (Elizabeth Kubler-Ross, 1969,
1974)
1) Denial - It is the immediate response to loss experienced
by most people and it is a useful tool for coping.
2) Anger - The client has no control over the situation and
thus becomes angry in response to this powerlessness.
The angry may be directed at self, God, and others.
3) Bargaining - The anticipation of the loss through death
brings about bargaining through which the client attempts
to postpone or reverse the inevitable.
4) Depression - When the realization comes that the loss
can no longer be delayed, the client moves to the stage of
depression. It helps the client detach from life to be able
to accept death.
5) Acceptance - The final stage of acceptance may not be
reached by every dying client, however, “most dying
persons eventually accept the inevitability of death, many
want to talk about their feelings with family members:
Verbalization of emotions facilitates acceptance.
J.A.K.E 10 of 16
Promotion of Comfort
- Relief of pain is critically important, the sooner the dying
client obtains pain relief, the more energy the client can
direct toward maintaining quality in the remainder of his
life.
- Provide personal hygiene measures, control pain, relief
respiratory difficulties, assists with movements, nutrition,
hydration and elimination, provide measures related to
sensory changes.
Promotion of Spiritual Comfort
• Support client in his expression of the philosophy he has
chosen for his life.
• Attentive listening encourages client to express feelings,
clarify them, and accept his fate.
• Praying silently with the client.
• Make referral for spiritual counseling.
• Facilitate expression of feeling, prayer, meditation,
reading, and discussion with appropriate clergy/spiritual
advisor.
Caring for Terminally Ill Patient
• Offer to listen and hear what the patient has to say. Avoid
being judgmental, and prepare to hear a variety of
emotions, including anger and frustration.
• Ask the patient what he needs or what would make him
more comfortable. Perhaps this is music, special books or
a visit from a certain person. Try to meet any requests the
patient has. If a request is not possible to fill, ask the
patient if there is anything else you can do as a substitute.
• Arrange to help the immediate family. Perhaps the spouse
could benefit from having meals prepared and brought to
him so he can be at his wife's bedside. Child care might be
needed. Reducing stress from the patient's loved ones
can also reduce the cancer victim's stress.
• Offer to record messages for the patient. Some patients
might wish to leave a video message for young children,
unborn grandchildren or others, which could be nothing
more than a legacy of who he is.
• Be present. If your friend or loved one is afraid to die, be
there for her. If you can't be present, arrange for others to
sit with her through her fear. You can only do so much and
be there so much, but your presence or the presence of
another person can be very comforting to a terminally ill
cancer patient.
• Incorporate things the patient likes into visits. If the
patient loves flowers, bring in fresh flowers for a visit. If
the patient loves a certain cookie, bring this if it's allowed.
If the patient loves to read but no longer can, bring a book
on CD for her to listen to.
• Offer comfort and as much understanding as possible.
Don't pretend to understand what the patient is going
through. You haven't died, and left loved ones so you don't
know what it is like to face certain death. Hugs and even
holding a hand might bring the patient much comfort.
Ethical Dilemmas Facing Gerontological Nurses
- Nursing practice involves many situations that could
produce conflicts-conflicts between nurses’ values and
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022

external systems affecting their decisions and conflicts decline as well, from memory recall abilities, to the
between the rights of patients and nurses responsibilities retention of new memories. Because of this, they need a
to those patients. lot of repetition and extra time to absorb and learn new
• Issues on Conflict of interest things.
• Issues on Confidentiality
• Issues on decision-making capacity The Role of the Brain in Communication
• Expanded Role of Nurses - The wider scope of - The brain has a major role in attending to new information,
functions, combined with higher salaries and greater making sense of and organizing information, and deciding
status, has increased the accountability and on a response. The information we receive through our
responsibility of nurses for the care of the patients. senses is not an exact re that exceed these physical
• Medical Technology – Artificial organs, genetic characteristics presentation of the real world.
screening, new drugs, computers lasers, ultrasound, - For example, our hearing is limited to frequencies of 20 to
and other innovations have increased the medical 20,000 hertz and our vision is limited to wavelengths of
community’s ability to diagnose and treat problems 400 to 700 nanometers.
and to save lives that once would have been given no
hope. However, new problems have accompanied Normal and Pathological Changes and their Impact on
these advances, such as determining on whom, when, Communication
and how this technology should be used. Impact on
Normal Pathological
Modality communicati
• Greater Numbers of Older Adults – Entitlement changes changes
on
programs and services for older persons had less
Changes in Macular
impact when a small portion of the population was Isolation,
lens, pupil, and degeneration
old, but with growing numbers of people spending insecurity,decr
iris Results in Diabetic
more years in old age and the increasing ratio of ease in
poor visual retinopathy
exchange of
dependent individuals to productive workers, society VISION acuity, Glaucoma
communicatio
is beginning to feel burdened. presbyopia, Senile
n,
• Assisted Suicide – The ANA has been clear in its increased cataracts
embarrassme
objection to assisted suicide, believing instead that sensitivity to Retinal
nt, depression
light and glare detachment
nurses should provide competent, compassionate
Inattention,
end of life care. However, although participating in a Conductive Hearing loss
repetitive
patient’s assisted suicide is unethical and problems due to
questions,
inappropriate, nurses may care for terminally ill Sensorineural exposure to:
isolation,
individuals who becomes even more complicated by problems noise,
insecurity,
Presbycusis ototoxic
the fact that laws have been enacted (e.g. Oregon’s decrease in
Results in loss substances,
death with dignity Act of 1997) to allow terminally ill HEARING social
in sensitivity to medications,
persons to end their lives with lethal medications, and functioning,
pitch with high poisons,
individuals have the right to refuse care under self- depression,
frequency acute trauma,
loneliness,
determination directives. consonants, certain
difficulties in
poor word medical
following
COMMUNICATING WITH OLDER PERSONS recognition conditions
instructions
- “Communication is the cohesive force in every human Decrease
culture and the dominant influence in the personal life of respiration
Deficits vary
every one of us.” “The form and function of Overproductio
dramatically
communication vary with the basic personality types and n of
but may result
age characteristics of the persons involved.” mucus/reduce
in: difficulties
- The mental facilities of the elderly change as a person d saliva Loss of Dysarthria
producing
ages, especially those that pertain to communication, like teeth Verbal
language,
Decreased apraxia
senses to memory. The elderly tend to withdraw and difficulties in
elasticity and Aphasia
disengage, but this can be made better through producing
SPEECH muscle tone Chronic
interpersonal communication. Communication is coherent and
AND Results in obstructive
therapeutic and it gives people a kind of strength, linking meaningful
LANGUAGE shaky and pulmonary
verbal
them to their environment and helping to regulate their breathy voice, disease
communicatio
own behaviors. It helps humans cope, it helps us maintain voice may Mechanical
n, or
alertness, and it helps us establish relationships with sound ventilation
difficulties in
people in our lives. tremulous, Laryngectomy
understanding
- Older adults change a lot as they age, both physically and frequent
verbal
attempts at
mentally. They can lose their major senses, like sight, communicatio
throat clearing,
smell, hearing, and taste, and lose the ability to move n.
changes in
affecting their sense of touch. Their mental abilities articulation,

J.A.K.E 11 of 16
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022

semantic your speaking pace, using a nice, relaxed tone, and lowers
errors the tone of your voice, but don’t necessarily raise your
Reduction in volume. Develop an ability to rephrase, act out, and
number of simplify what you’re trying to express. Make sure you are
receptors
Many medical in a quiet and comfortable environment. A common age-
Reduction in
conditions Use of the related barrier is hearing loss (presbycusis), affecting how
blood flow
such as mouth to well older adults hear what you’re saying and how you’re
Results in a
dementia, explore the saying it, and vision loss (presbyopia), affecting how they
reduction in
TOUCH Parkinson’s, quality of the
tactile and “hear” your nonverbal communication—gestures, facial
or diabetes objects, safety
vibration expressions, and body language, as well as reading
can impact might be
sensations, written messages and seeing signs and symbols. Possibly
somatosenso compromised
decreased the most frustrating communication barrier occurs when
ry functioning
sensitivity to the message is heard, understood, and simply ignored.
warm or cold
Attitude issues due to a poor relationship between the two
stimuli
Parkinson’s
communicators can cause this.
disease
Due to decline Reduced Ways to communicate with seniors?
Disability
in many ability to
Results in • Allow extra time for older patients.
sensory communicate
organs,
reduced
nonverbal • Avoid distractions.
MOVEMENT velocity and • Sit face to face.
cognitive information,
accuracy and
functioning, insecurity, and • Maintain eye contact.
greater
and bodily
variability
loss of • Listen. ...
strength independence • Speak slowly, clearly and loudly.
across
individuals • Use short, simple words and sentences.
Depending on • Stick to one topic at a time.
cognitive
impairment, Communication with Older Person Topics
Decline in loss may
Information Sharing
information result in
processing complete
- Help older people make informed decisions by sharing
speed, divided disorientation information in the way they prefer writing or demonstrating
attention, and something can be helpful.
Delirium - Avoid sharing too much, too quick.
sustained inappropriate
Dementia:
COGNITIVE attention, response, - Unfamiliar situations can be overwhelming, so slow down
Alzheimer’s
ability to difficulties and allow people time to process the information.
disease
perform finding words,
visuospatial depression. - Verbal communication
tasks, and Loss of insight,
• involves sending and receiving messages by means of
short-term isolation, or
memory impairment in words
ability to learn • some verbal communication is formal, structured,
new and precise; Some is informal, unstructured, and
information flexible
In general, • nurses must be effective in both formal and informal
older adults Slowed communication and Must know how and when to use
report levels of response, lack each type
PSYCHOLO
satisfaction Depression of motivation,
GICAL - Nonverbal communication
that are similar decrease in
to those of social activity • Takes place without words
younger adults • Research has shown that only 7 % of communication
- Communication is a two-way street, and you must be a comes From the actual words we use; the other 93%
good listener and recognize the challenges your speaker is nonverbal
faces. • Approximately 38% of communication is transmitted
- When communicating with the elderly, you must listen, by Paralinguistic cues (i.e., tone, pitch and volume of
pay attention, maintain eye contact, and display an active voice), and 55% is transmitted by body cues.
posture. You have to find a reason for listening (so you Formal or Therapeutic communication
naturally show a real interest in what they are saying), - Therapeutic communication - a conscious and deliberate
show respect through maintaining personal space, and process used to gather Information related to a patient’s
get on eye level with the person you’re speaking with. Be overall health status (physical, psychosocial, spiritual,
aware of your own non-verbal communication and body etc.) And to respond with verbal and nonverbal
language, as well as keeping an eye on theirs. Slow down

J.A.K.E 12 of 16
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
- Approaches that promote the patient’s well-being or
improve the patient’s understanding of ongoing care.
- Careful use of words and language is an art.
- Knowledge of the individual’s educational background
and interests provides Nurses with a starting point for
conversation.
- Social discussions often center on past employment,
family, or other interests.
- Increased know ledge of the individual enhances then u
rse ’s ability to respond empathetically.
- Effective verbal communication requires the ability to use
a variety of Techniques when sending and receiving
messages.
- Nurses should know as much as possible about the other
person involved
- A person’s age, marital status, cultural or ethnic
orientation, educational background, interests, and the
ability to hear and see influence the communication
techniques used and the words chosen
- As nurses, we need to be careful to choose words that the
patient can understand—not so simple that we are
“talking down” to the patient, but also not so technical or
“medical” that the meaning is unclear.
- Avoid acronyms such as TURP or CBC unless you are sure
that the person understands them.
Here are six tips to effectively communicate with
individuals non-verbally, and to help work through the
challenges that caregivers and family members often face:
1) Personal Appearance - Appropriate clothes, hair and
body scent can make a person with dementia more
relaxed and comfortable with you, because that may
remind them of someone they knew.
2) Approach Individuals from the front - People will
become more familiar with you when they feel like they
are being respected. By approaching them from the front,
you will give them a chance to process who you are and
what you are asking.
3) Body Language/ Eye Contact - A person with dementia
will be able to detect your body language, sudden
movements which can cause distress on the person and
can make it hard to communicate. Demonstrating what is
being asked will give the person a visual perception.
Respect the person’s personal space but make sure to
drop down to eye level, this will allow the individual to feel
more comfortable and in control of the situation.
4) Facial Expressions -Tense facial expressions can also
cause distress. Soft facial expressions and smiling will
give the person enjoyment. So remember, something as
simple as starting a conversation with a smile can go
along way!
5) Touch - Physical contact will give the person a sense of
care and affection. Simply by holding someone’s hand,
rubbing their shoulder or giving them a hug will provide
reassurance and comfort.
6) Dance/ Music - Music and dance can spark memories of
happy times in a person’s life. Make sure to know what
type of music a person enjoyed growing up and allow
them to create moments of joy.
J.A.K.E 13 of 16
GUIDELINES FOR EFFECTIVE DOCUMENTATION
- Documentation tells the story of each patient’s journey
throughout the entirety of each episode of care. From
initial admission through the treatment process and
discharge, important details are carefully noted, allowing
you and other caregivers to spot patterns and potential
challenges so you can provide the absolute best level of
care possible and avoid potential setbacks.
10 Tips for Better Documentation
1) Remember that any reviewer of a patient record does not
have the depth of knowledge that is gained from providing
care. Because of this, document objective and clear
findings and information, including the patient’s problems
and needs, the care provided, and how the care is
directed toward goal achievement and discharge.
2) The contents of the documentation should convey to any
reader, such as your manager, a state or accreditation
surveyor, or a payer, the status of the patient, adherence
to the ordered plan of care, and progress toward
individualized patient-centered goals.
3) Document both medical necessity and homebound and
support other coverage criteria in your documentation. For
home care and hospice care, use objective descriptive
terms that help the reviewer “see” your patient and their
functional and other limitations that support a knowledge
of the tenets of coverage for your program.
4) Look at the documentation objectively. Does it tell the
story of the patient, their care trajectory, and the
interventions provided and implemented based on
physician orders?
5) Make sure calls and other communication across team
members and the physician are documented. If the
patient experiences a change in condition, does the
documentation explain what the findings were or what
occurred with the patient that necessitated the call? Does
it include what actions were ordered or changed and
implemented as well as the patient’s response to these
interventions and care?
6) Are the patient’s areas of risk for hospitalization noted and
observed? Are the interventions to prevent this
reoccurrence documented?
7) Does each visit by a clinician include the elements of
assessment, care planning, interventions and actions,
and continued evaluation?
8) Documentation should include patient and family
caregiver education, their responses to and
demonstration of the education provided, as well as
results of the education (for example, medication
administration).
9) The care entries and overall information need to reflect
the level of care expected by healthcare consumers,
caregivers, and their families.
10) Overall, the clinical documentation should demonstrate
compliance with regulatory, licensure, and quality
standards. Ask yourself the value question: Would I pay
for this care or visit? Is this reflected in the clear
documentation that supports medical necessity and
coverage?
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
Confidentiality
- Refers to the duty to protect privileged information and to
share entrusted information responsibly. It stems from the
notion that a person’s wishes, decisions, and personal
information should be treated with respect.
- The duty of confidentiality can apply to individuals,
organizations, and institutions. In fields like medicine, the
law, and counseling, there are explicit, professional
obligations to keep personal information in confidence,
because the trust is the foundation for meaningful
professional relationships.
- As a general rule, health care providers have a
responsibility to avoid disclosing personal and medical
information that has been entrusted to them without the
patient’s consent. In accordance with professional
standards, when a patient’s private information is shared,
there is the expectation that health care providers will
keep the information in confidence. This might include
details pertaining to a patient’s diagnosis, prognosis,
history of illness, drug use, family history, and sexual
activity.
Privacy
- Refers to the right to be free from interference. Privacy is
supposed to enable individuals to exert control over their
own lives, which includes deciding who should have
access to personal information, and when and how this
information will be disclosed.
- Although there continues to be vigorous debate about
whether the U.S. Constitution guarantees a right to privacy,
the legal basis for the right to privacy typically stems from
the Fourteenth Amendment. In Florida, the right of privacy
is discussed within the state’s constitution in Article I,
Section 23.
Health Insurance Portability and Accountability Act of
1996 (HIPAA)
- A federal law that was created in part to protect
information contained within the medical records of
patients. One of the primary goals of HIPAA was to
establish federal standards regulating how electronic data
is transmitted and shared. In principle, storing medical
records electronically can give physicians, insurance
companies, and other parties easier access to these
records, which raises concern that private information
might be shared without the knowledge or consent of
patients.
- In most circumstances, under the revised HIPAA
guidelines, health care providers are required to obtain a
patient’s consent before confidential information is
shared with other parties. Depending on the situation, a
physician’s office may be required under HIPAA to provide
written notice of privacy practices to the patient. This
notice should include the rights that the person has as a
patient and the measures that will be used to keep his/her
personal and medical information private. HIPAA also
regulates marketing practices in order to protect a
patient’s information from being sold and distributed to
J.A.K.E 14 of 16
health plans, pharmacies, and drug companies without
the patient’s consent.
- Although there remain disputes concerning what the
concepts of privacy and confidentiality precisely entail, it
is generally agreed that they are not absolute notions. The
level of privacy that one can reasonably expect, for
example, varies dramatically depending on the context.
One’s privacy can appreciably diminish when one
discloses information in a public area. Medical
information that a patient discusses with his/her
physician while walking in a city park might be overheard
by other individuals. Yet if this information is discussed
while in a private office, it is more likely that privacy can
be maintained.
- Concerns of justice and of upholding the common good
can sometimes supercede the duty to keep information
confidential. In most circumstances, health care
providers must obtain a patient’s consent before sharing
that patient’s information with other parties. Yet there are
rare circumstances, such as when a court order has been
issued, wherein a physician may be legally obligated to
disclose a patient’s information without the patient's
consent. Similarly, a physician might have a “duty to warn”
the state if it is believed that a patient poses an obvious
threat to other individuals. With regard to elderly patients,
it is a fairly common problem that a physician treats an
elderly individual who is unwilling to stop driving a car, but
whose physical or mental capacity to do so may be
compromised. This type of situation illustrates the tension
that may arise between the obligation to keep the
patient’s information in confidence and the obligation to
prevent the patient from causing harm.
- The importance of privacy and confidentiality to elderly
patients should not be overlooked. Although health care
teams, family, and friends might assume that these
concepts are unimportant to an elderly patient, the
patient might not agree. A competent patient should
expect that information shared with a health care team
will be kept confidential regardless of the patient’s age.
Further, if privacy is maintained, this might enable elderly
patients to feel that they have an appreciable level of
control over their own lives even when they are in the
hospital. Health care teams should not, for example,
automatically assume that an elderly patient wants family
and friends in the hospital room when personal and
medical information is being shared. The desire to
maintain one’s privacy does not necessarily decline with
age.
HIPAA Privacy Rule
- The Privacy Rule standards address the use and
disclosure of individuals’ health information (known as
“protected health information”) by entities subject to the
Privacy Rule. These individuals and organizations are
called “covered entities.” The Privacy Rule also contains
standards for individuals’ rights to understand and control
how their health information is used. A major goal of the
Privacy Rule is to ensure that individuals’ health
information is properly protected while allowing the flow
of health information needed to provide and promote high
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022
quality health care and to protect the public’s health and
well-being. The Privacy Rule strikes a balance that permits
important uses of information while protecting the privacy
of people who seek care and healing.
Covered Entities
The following types of individuals and organizations are
subject to the Privacy Rule and considered covered entities:
1) Healthcare providers: Every healthcare provider,
regardless of size of practice, who electronically transmits
health information in connection with certain transactions.
These transactions include claims, benefit eligibility
inquiries, referral authorization requests, and other
transactions for which HHS has established standards
under the HIPAA Transactions Rule.
2) Health plans: Entities that provide or pay the cost of
medical care. Health plans include health, dental, vision,
and prescription drug insurers; health maintenance
organizations (HMOs); Medicare, Medicaid,
Medicare+Choice, and Medicare supplement insurers;
and long-term care insurers (excluding nursing home
fixed-indemnity policies). Health plans also include
employersponsored group health plans, government- and
church-sponsored health plans, and multiemployer health
plans. Exception: A group health plan with fewer than 50
participants that is administered solely by the employer
that established and maintains the plan is not a covered
entity.
3) Healthcare clearinghouses: Entities that process
nonstandard information they receive from another entity
into a standard (i.e., standard format or data content), or
vice versa. In most instances, healthcare clearinghouses
will receive individually identifiable health information
only when they are providing these processing services to
a health plan or healthcare provider as a business
associate.
4) Business associates: A person or organization (other
than a member of a covered entity’s workforce) using or
disclosing individually identifiable health information to
perform or provide functions, activities, or services for a
covered entity. These functions, activities, or services
include claims processing, data analysis, utilization
review, and billing.
Permitted Uses and Disclosures
A covered entity is permitted, but not required, to use and
disclose protected health information, without an individual’s
authorization, for the following purposes or situations:
1) Disclosure to the individual (if the information is
required for access or accounting of disclosures, the
entity MUST disclose to the individual)
2) Treatment, payment, and healthcare operations
3) Opportunity to agree or object to the disclosure of PHI
(Informal permission may be obtained by asking the
individual outright, or by circumstances that clearly give
the individual the opportunity to agree, acquiesce, or
object)
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4) Incident to an otherwise permitted use and disclosure
5) Public interest and benefit activities — The Privacy Rule
permits use and disclosure of protected health
information, without an individual’s authorization or
permission, for
12 national priority purposes external icon:
1) When required by law
2) Public health activities
3) Victims of abuse or neglect or domestic violence
4) Health oversight activities
5) Judicial and administrative proceedings
6) Law enforcement
7) Functions (such as identification) concerning deceased
persons
8) Cadaveric organ, eye, or tissue donation
9) Research, under certain conditions
10) To prevent or lessen a serious threat to health or safety
11) Essential government functions
12) Workers compensation
HIPAA Security Rule
- While the HIPAA Privacy Rule safeguards protected health
information (PHI), the Security Rule protects a subset of
information covered by the Privacy Rule. This subset is all
individually identifiable health information a covered
entity creates, receives, maintains, or transmits in
electronic form. This information is called “electronic
protected health information” (e-PHI). The Security Rule
does not apply to PHI transmitted orally or in writing.
- To comply with the HIPAA Security Rule, all covered
entities must do the following:
• Ensure the confidentiality, integrity, and availability of
all electronic protected health information
• Detect and safeguard against anticipated threats to
the security of the information
• Protect against anticipated impermissible uses or
disclosures
• Certify compliance by their workforce
- Covered entities should rely on professional ethics and
best judgment when considering requests for these
permissive uses and disclosures.
- The HHS Office for Civil Rights enforces HIPAA rules, and
all complaints should be reported to that office. HIPAA
violations may result in civil monetary or criminal
penalties.
Multidisciplinary Team Working
Team member Activity assessed and promoted
Mobility, balance and upper limb
Physiotherapist
function
Occupational ADL, e.g. dressing, cooking Home
Therapist environment and care needs
Dietitian Nutrition
Speech and
Communication and swallowing
language therapist
Care needs and discharge planning,
Social worker including organization of institutional
care
Nursing specialist who works directly
Nurse Gerontologist
with older adults to provide them with
 CARE OF OLDER ADULTS – LEC: BSN 3RD YEAR 1ST SEMESTER MIDTERM 2022

specialized care and a high quality of life.

Motivation and initiation of activities,
promotion of self-care Education
Feeding, continence, skin care
Communication with relatives and other
professionals Assessment of care needs
for discharge
Diagnosis and management of medical
problems Coordinator of assessment,
Doctor
management and rehabilitation
programme
Someone who has an advanced
education in the field of gerontology, the
study of aging. They're professionals who
specialize in issues of aging or
professionals in various fields from
dentistry and psychology to nursing and
Gerontologist
social work who study and may receive
certification in gerontology. Researchers,
educators, policy makers and
practitioners in health, allied health and
aged care, as well as others engaged in
ageing issues
An expert in the branch of medicine or
Geriatrician social science dealing with the health
and care of old people
to undertake assessment, monitoring,
planning, advocacy and linking of the
Case Manager
consumer with rehabilitation and support
services

Terminologies
• Confidentiality - pertains to the treatment of information
that an individual has disclosed in a relationship of trust
and with the expectation that it will not be divulged to
others without permission in ways that are inconsistent
with the understanding of the original disclosure.
• Privacy is the ability of an individual or group to seclude
themselves or information about themselves, and thereby
express themselves selectively. When something is
private to a person, it usually means that something is
inherently special or sensitive to them.
• Health Insurance Portability and Accountability Act of
1996 (HIPAA) The Health Insurance Portability and
Accountability Act of 1996 is a United States federal
statute enacted by the 104th United States Congress and
signed into law by President Bill Clinton on August 21,
1996.

GOOD LUCKKK WITH UR MIDTERM EXAM, FUTURE NURSES!!

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