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Care giving cont public issue
- care giving considered a major public health issue:
- Inc demands on home services
- - shorter hospital stays with limited d/c planning
- - better technology available in the home
- - aging population
- estimation by CDC:
- need for family caregivers will incr by 85% (by 2050) but available members to provide care will decre
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positive aspects of caregiving
- enhanced self esteem and wellbeing
- personal growth and satisfaction
- finding or making meaning thru caregiving
- relationship prior is important
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Spousal care giving wife v husband
- Wives:
- may need to learn to:
- drive
- manage money
- makes decisions by themselves
- Husbands:
- may need to leanr to
- cook
- shop
- do laundry
- provide personal care for their wives
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Nursing assessment
- comprehensive assessment
- - identify the family members- family dynamic
- - the functions of each family member esp caregiver
- - include a family medical hx
- - sources of stress and methods of coping
- - support system
- cargiver assessments includes stressors and benefit
- nurses perform a risk assessment of caregiver stress
- nurses respite care- long term care- caregiver may need a break
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Nursing interventions
- focuses on strengths of the family unit
- build on strengths
- identify weakness and provide support and those areas
- ** goal is to maintain health and wellingbeing of family unit
- most families are in crisis before nurses become involved
- avoid personal beliefs or definition of family
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Mistreatment: identify abuse and neglect of older adults
- a person in need is at risk for harm from the care giver
- the caregiver struggles with frustration, anger, fraudulent and carelessness in giving care
- mistreatment leads to abuse and neglect
- Abuse: seems to be episodic and recurrent can be physical, psychological, sexual, financial
- Medical Abuse: subjecting a person to unwanted treatment or procedures
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Mistreatment: identify abuse and neglect of older adult
neglect
- Neglect: an identified caregiver has not met their obligation to care for the family members
- self neglect: the older adult is not caring for themselves in a manner in which their peers do
- medical neglect: is when desired treatments are withheld
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Characteristics of elder abuse and neglect
- frequent unexplained crying
- unexplained fear or suspicion of a particular person
- sudden changes in behaviors
- caregivers refusal to allows vistors to be alone with them
- inconsistents stories
- missed appt (red flag)
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As risk elders
- Home setting
- spouse or children as caregivers
- women
- past hx of abuse
- target is viewed as aggressive, combative or unappreciated
- incr dependency= incr tendency to be abused
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Physical abuse
- Broken bones, sprains, lacerations
- injuries in various stages of healing
- elders report of being mistreated
- lab findings of meds overdose or under dose
- broken eye glasses or frames
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sexual abuse
- nonconsensual sexual contact at anytime
- includes any sexual contact with any person who is incapacitated or unstable to give consent
- s/s:
- - torn clothing
- - unexplained STD
- - unexplained vaginal or anal bleeding
- - elders report
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Emotional or psychological abuse
- be aware of behaviors:
- - withdrawn- flat affect
- - upset or agitated
- - unusual behavior (absent or dementia)
- ---biting hitting rocking
- - elders report
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Neglect
- any refusal or failure to fulfill any part of an elder's caregiving obligations including life necessities
- S/s:
- - dehydration, malnutrition or poor hygiene
- - untreated bedsores
- - unsanitary or hazardous conditions
- ---lice, dirt on person, fecal or urine smell
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abandonment
- desertion of an individual by a person who has assumed care
- s/s
- desertion of an elder at an institution or any public location
- elders report
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Prevention of mistreatment
- geronto nurses are alerted to situation that can cause mistreatment to older adults
- geron nurses can identify potential victims
- nurses can work with caregivers and community support
- team approach
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Evidence based practice: prevention of elder abuse and mistreatment
- learn how to access for actual or potential abuse
- know your state statutues and regulations related to the nurses role in elder abuse and reporting suspicions
- keep informed, attend continue education programs
- help care givers find and obtain respite services for intermettent relief
- help care givers and pt broaden their social network support
- provide money management programs for care giver and elder
- help families develop and nurture informal support systems
- link families with support groups
- teach families stress management techniques
- arrange comprehensive care resources
- provide counseling for high risk familes
- utilize other family members
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Mandatory reporting
- Licensed nurses are required to report suspicions of abuse to the state
- reports to be anonymous
- need solid evidence
- ** mentally competent adults cause refuse assessment and intervention and cannot be removed from harm without their permission
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Competency and capacity
- terms can be used to identify the person ability to make decisions and understand the consequence of his actions and choices
- capacity: is the ability to handle finances, daily business, take care of self, make medical decisions
- - the person has the ability to decline or accept medical tx
- one maybe limited capacity in one area (paying bills) but still be able to make healthcare decisions
- when the capacity of an individual is impaired and no longer can make decision the courts will determine if person is incapacitated
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Guardians and conservators
- are individuals, agencies or corporations that have been appointed by the court to have care, custody and control of a disabled person to manage financial responsibilites
- guardian is a person appointed to be responsible for another person
- conservator is a person specifically appointed to control the finances of the client
- both remain in effect until court rescinds the order
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decision making at the end of life
- causes legal, ethical medical and personal concerns
- as the result of technology the line between living and dying is blurred
- advance directive includes:
- - living will
- - durable power of attorney for health
- - medical powers of attorney
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Power Of Attorney
- is a legal document that gives the designated person (relative or friend) the power to act on the behalf of a person
- a specific request of the elder
- may be activated when elder can longer act on their own behalf
- as soon as person regains ablity it is no longer enforced (unless requested)
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Types of power of attorney (POA)
- General POA
- - right to make financial decision, pay bills etc
- Durable POA (surrogate or proxy)
- - additional rights to make healthcare decision
- - allowed to make end of life decisions- advise the proxy is someone who will uphold person's wishes
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Loss and grief
- loss can be physical function due to normal aging
- Life transition:
- - retirement
- - moving from family home (loss of house down size)
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Grieving Process
- First period of the grieving process is acute grief
- - physical
- - psychological
- Middle period- despair or depression
- - affects the day to day functioning of a person
- Final Phase of the grieving process
- - the person learns to adjust to life in a new way
- process is not a rigid structure
- pattern of grief is not always predictible
- may flucuatuate back and forth
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Loss response model
- person is in a state of disequilibrium
- grieving family member search for meaning
- loss becomes "real" as the person repeats the story
- - shares emotions thru retelling: anger, frustration, relief
- family structure is reorganized
- change is accepted
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Types of Grief
- in older adult the reaction to grief may be mistaken for another condition such as dementia
- types of grief include:
- - anticipatory guidance- perceive loss before it happens
- - Acute- crisis
- - chronic- PTS around aniversary
- - disenfranchised- loss not publically mourn- no support
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factors affecting coping with loss
- those at risk for adverse affects include:
- - older spouses
- - life partners
- intense grief may cause a decre in cognitive function, such as dementia
- decre in ability to mobilize or make decision
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Coping
- Those who effectively cope:
- - maintain composure
- - use good judgement
- - opitimistic without denying the loss
- - talk openly about the challenges
- Those who ineffectively cope:
- - are more rigid and pessistimic
- - are demanding
- - have emotional extremes
- - live alone, socialize little, have a few close friends
- - may have a history of mental illness
- - may have guilt
- - may abuse alcohol and other substances
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Nursing Implication for loss
- Goal: a healthy adjustment to loss
- individual assessment: grief and coping assessment:
- - personal growth
- - continuing bonds
- - health risk
- working with grieving older adults is normal part of the work day for a geron nurse
- nurses uses the skills of therapeutic communication
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Nursing intervention of loss
- know the stages of transition
- During crisis establish rapport:
- - tell nurse role
- - provide safe environment
- - provide basic needs (food, rest)
- - avoid fostering false hope but reassure availablity for assistance
- middle transition provide support- allow the person to talk about loss
- help build strength and confidence- reframe the memories to complete the cycle
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nursing inventions continue loss
- Reminiscence therapy:
- - to help accept and find meaning in life
- - relating their story can result in a sense of self worth and acceptance
- Allow for opportunity to express ones feelings:
- - journaling- helps the person feel at peace
- - daily list of things they appreciate
- - use of lifting quotes
- Pet Therapy:
- - stimulate sharing of feeling from past memories
- photo albums: allow for reflection of past events
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countercoping
- the client copes and the nurse countercoping
- strategies of countercoping include:
- - clarification and control= gathering infor
- - collaboration- repeat stories
- - direct relief- acting out feelings
- - cooling off- put grieving aside and reestablish life
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dying death and pallative care
- death is not the problem, dying the work
- dealing with dying reflects ones own culture
- older adult death seems normative
- if the dying process is viewed as long and painful- then dying is viewed as a relief
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conceptual models- Dr. Kubler ross stages of death
- Dr. Elizabeth Kubler- Ross stages of death:
- - denial
- - anger
- - bargaining maybe it can changes
- - depression- why me
- - acceptance- help us move forward and plan for future
- all stages are emotional reactions to dying
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Living- dying interval
- dying begins at the moment called "crisis knowledge of death and ends at the moment of physiological death
- the living-dying interval is the time between these two points
- the chronological timeframe depends on the remissions and exacerbation in the diagnosis of a terminal illness
- dying may take days, weeks, months, or years
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Dying time
- crisis intervention is most important at this point
- antipatory grieving may occur
- most time is spent in chronic phase
- life can still be lived bc it does go on, despite the antipated end
- terminal phase is when the speed of physical dying is accelarated an the person no longer has the energy to maintain the activities of everyday life
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Response to death
- The person who is dying may:
- - withdrawl from outside work
- - engage in coded communication
- - give away cherished items
- - urgently contact friends and family
- In some cultures these actions occur during a period termed death watch
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Responsibilities of the nurse during dying period
- provide safe care to the person and family
- meets the needs of the dying person
- uses the 6 C's approach:
- - care
- - control
- - composure
- - communication
- - continuity
- - closure
- helps pt and family thru process
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role towards family
- nurses are appreciated:
- - if they keep family informed
- - ask how family members are doing and offer support
- - offer comfort when a family member cries and often cries too
- - brings food
- - knows fam members names
- - brings bed to the clients room for fam members
- - holds hand of fam member
- - advises fam member holds hand of the dying
- - calls a chaplian when need
- - stays after their shift duties are over
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Dying and the nurser
- death of client is not the failure of the nurse
- nurses provide safe comfort to the dying and gentle care to the family
- nurses must know the grieving process
- nurses must have coping skills such as meaning making and the ability to disengage
- nurses must be comfortable with their own lives
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pallative care
- nurses care for older adults with irreversible and progressive chronic conditions (alzheimer disease, parkinson)
- is the time when the client does not want anymore tx
- focus is on care and comfort v cure
- hospice care is an option
- - generally reserved for terminal conditions
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Nurse role in pallative care
- staff nurse giving direct care
- nursing coordinator implementing the plan of the interdisciplinary team
- nursing executive officer being responsible for clinical care
- nurse advocacy for humane care foe the person whi is fying and his or her family
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Euthanasia
- is the client's right to refuse life sustaining medical measure
- terms associated with euthanasia incluse:
- - physician assisted death
- - physician assisted suicide
- - physician helping the client during the dying process
- - passive and active ethanasia
- doctors are allowed to prescribed lethal medication injections in five states
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What is spirtuality?
- religious faith and practices
- can also be experienced and understood in non religious ways
- spirituality is suggested as:
- - the search for the scared
- - a process of self-discovery in relation to a meaning of life
- it is the central philosphy of life which guides a person through the dimension of human nature
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Spirituality and healthcare
- positive outcomes linked to spirtuality
- higher religious spirituality
- - decre levels of death
- - decre anxiety/alcoholism
- - better marriages
- - decre loneliness
- - less distress among dementia care givers
- better mental health
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Nursing consideration- spirituality
- help individuals find meaning and purpose in living
- stayed connected and engaged with oneself, others and the larger world
- allow them ample time to articulate what brings them meaning and purpose
- encourage self reflection
- how can we support those activities or beliefs that will help them stay connected
- assist with creative ways to support the spiritual journey of aging
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Nurturing the spirit of the nurse
- nurses must consider:
- what gives their own life meaning and value
- will assist them in offering spiritual support to pts
- taking care of nurses own spiritual needs help them to better meet the pt's spiritual needs
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