Case Studies in Gerontological Nursing for the Advanced Practice Nurse

Meredith Wallace Kazer, Leslie Neal-Boylan

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118277843
• Edition: 1
• Topic: Medicine
• Subtopic: Gerontology Nursing

As the fastest growing population sector worldwide, older adults are seen in almost every care setting in which clinicians practice. Developed as a resource for advanced practice nurses in any setting, Case Studies in Gerontological Nursing for the Advanced Practice Nurse presents readers with a range of both typical and atypical cases from real clinical scenarios.

The book is organized into six units covering cases related to ageism, common health challenges, health promotion, environments of care, cognitive and psychological issues, and issues relating to aging and independence. Each case follows a similar format including the patient's presentation, critical thinking questions, and a thorough discussion of the case resolution through which students and clinicians can enhance their clinical reasoning skills.

Designed to promote geriatric clinical education through self-assessment or classroom use, Case Studies in Gerontological Nursing for the Advanced Practice Nurse is a key resource for all those dedicated to improving care for older adults.

Section 1: The Aging Population

Case 1.1 Recipe for Successful Aging

By Christine Tocchi, PhD(C), MSN, APRN, GNP-BC

Case 1.2 Cultural Competence Is a Journey

By Jina Ko, MSN, RN, ANP-C and Julie M. L. Lautner, MSW, MSN, RN

Case 1.3 The Ugly Face of Ageism

By Shelley Yerger Hawkins, DSN, APRN, FNP, GNP, FAANP

Case 1.4 If Only We Had National Health Insurance

By Philip A. Greiner, DNSc, RN

Case 1.1

Recipe for Successful Aging

By Christine Tocchi, PhD(C), MSN, APRN, GNP-BC

Mrs. R presents to the primary-care practice for an annual examination. She is new to the practice and has several health questions she would like to discuss regarding aging as she is now a “senior” and needs to stay healthy to care for her 88-year-old mother with early stage Alzheimer disease. Mrs. R is 65 years old and describes her overall health as good. She was diagnosed with hypertension and hypercholesterolemia approximately 15 years ago and has been seeing her former primary physician every 6 months for checkups. Mrs. R also has osteoarthritis of the right knee with occasional pain and stiffness. She is concerned that she may need to have knee replacement surgery in the future. Mrs. R recently relocated to a new apartment to accommodate being the primary caregiver for her mother. Mrs. R is not sure how to manage her mother’s routine health care.

Mrs. R has a past medical history of hypertension, hypercholesterolemia, and osteoarthritis of the right knee. Her past surgical history includes a tonsillectomy at age 7 and cholecystectomy at age 41. Her medications are: HCTZ, 12.5 mg daily; atorvastatin, 20 mg daily; and Tylenol Arthritis, 2 tablets as needed for knee pain with an average of once a day administration and twice a day “on bad days”. She has a mammogram annually. Her last Pap smear was 2 years ago. She had a colonoscopy at age 55. Both tests revealed no abnormal findings. TB: unknown. She has no known allergies (NKA). Her functional status reveals that she is independent in all activities of daily living and instrumental activities of daily living. She drives her own automobile. Her father died at age 63 of myocardial infarction (MI). Her mother is alive, age 88, with a history of mild stage Alzheimer disease, hypercholesterolemia, and osteoarthritis of both knees. Mrs. R is not sure of her paternal and maternal grandparents’ health history. Mrs. R has 2 brothers ages 69 and 67 living in Puerto Rico with unknown health history. She has 2 younger brothers living in the United States. Her 60-year-old brother has a health history of MI at age 48, hypertension, and diabetes mellitus. Her 57-year-old brother has hypercholesterolemia. Mrs. R also has 2 sisters living in the United States. One sister, age 62, has diabetes mellitus, hypertension, and a history of breast cancer. Her 55-year-old sister is alive and in good health. Mrs. R also has 3 children: 2 sons, ages 42 and 40, are both in good health; and her daughter, age 37, is also in good health. She has 8 grandchildren.

Mrs. R is a recently retired home health aide. She has a high school diploma and has received certification as a home health aide. She is divorced and currently residing in a 2-bedroom apartment of a 2-family house with her 88-year-old mother. Mrs. R is the primary caregiver for her mother. One sister lives locally and works full-time. This sister lives with her family on the first floor of the 2-family house. The sister sporadically assists with primary caregiving of mother when she is not working. Mrs. R’s other siblings live within 20 miles but only visit during the holidays. Mrs. R’s children all live locally, work full-time, and have children. Mrs. R provides child care for her daughter’s 7- and 10-year-olds after school 3 days per week. Her son’s family comes to dinner every Sunday. Mrs. R has a boyfriend whom she sees approximately 3 times per week. The couple dines at a local restaurant weekly without her mother.

Mrs. R states that her finances are adequate and include Social Security and a “small” amount of savings. She also does alterations occasionally for a local tailor for extra income. Mrs. R has a 20 pack year history of smoking. She has not smoked for 25 years. Mrs. R denies a history of alcohol abuse or use of recreational drugs. She has approximately 1 glass of wine per day with dinner. Mrs. R is sexually active. She denies dyspareunia or sexual problems with herself or her partner. She has no history of sexually transmitted diseases.

Hobbies:

Mrs. R enjoys cooking and has a weekly card game with her girlfriends. Most of her day is spent shopping, doing housework, babysitting, and overseeing the care of her mother.

Mrs. R currently denies any pain, discomfort, or constitutional symptoms. She does state that she has intermittent right knee pain associated with arthritis. The pain and stiffness occur on cold or rainy days and with extended walking or sitting. The pain is described as a “bad ache,” 7 on a scale of 1–10; and its duration is 30 minutes to 1 hour. Stretching, heat, and Tylenol Arthritis are all effective. She averages 2 Tylenol Arthritis tablets per day and twice a day on “bad days”. She denies headache. Mrs. R states that she has noticed some difficulty with blurred vision at night when driving and requires reading glasses for any “close work”. She denies any hearing loss or tinnitus. She denies nasal congestion, drainage, epistaxis, sore throat, or a cough. On a rare occasion, she has experienced dyspnea on exertion without chest pain or palpitations, which is relieved with rest. Mrs. R also denies any abdominal pain, nausea, vomiting, constipation, or diarrhea. On occasion, she has experienced indigestion after a large meal, which is relieved with Tums. She complains of rare stress incontinence with laughing or sneezing, but no urge incontinence, dysuria, hematuria, or retention difficulties. She wakes to void once per night. Mrs. R denies any vaginal drainage. She denies any joint pain except knee pain. She denies muscle weakness, paresthesia, edema, or difficulty with balance or gait. Mrs. R denies episodes of lightheadedness, vertigo, syncope, tremors, or falls in the past 6 months. She describes her mood as good, without depressive symptoms, anxiety, or mood swings. She also describes her memory as good with rare “forgetfulness” of names or misplacing things but “it always comes to me in a couple of minutes”.

OBJECTIVE

Mrs. R is a 65-year-old female in no acute distress. Her BP is 126/78; her pulse is 78; and her respirations are 12. She is 64 inches tall and weighs 125 lb. Her head is normocephalic. PERRLA. External ear canals are without drainage, erythema, or swelling. Her TMs are intact. Her neck is supple. There is no evidence of lymphadenopathy, thyroidomegaly, or carotid bruits. Her thorax is symmetrical, and her breath sounds are clear to auscultation. Cardiac examination reveals S1, S2 with no murmurs, gallops, or clicks. Her abdominal examination is benign. Her extremities have no evidence of cyanosis, clubbing, or edema. Her neurological examination is nonfocal, without evidence of rigidity, myoclonus, cogwheeling, or tremors. She has a positive get-up-and-go test, and her Romberg sign is negative.

CRITICAL THINKING

What are the current statistics on life-expectancy trends of the older adult population that will guide recommendations for care for Mrs. R?

How can Mrs. R successfully age without becoming dependent on others for physical support?

What are the current rates of disability in older adults and methods to prevent disability?

What are the most important areas to assess in Mrs. R. in order to help to promote health and prevent disease and complications associated with chronic illness?

What is the plan of treatment for Mrs. R based on her history and physical examination results?

RESOLUTION

What are the current statistics on life-expectancy trends of the older adult population that will guide recommendations for care for Mrs. R?

The growth in the number and proportion of older adults in the United States is increasing at an unprecedented rate. The older adult population is currently 12.8% of the U.S. population; 1 in 8 Americans are greater than 65 years of age. It is estimated that this population will increase to approximately 20% by the year 2030 (U.S. Department of Health and Human Services, 2008). The older adult population comprises a large heterogeneous group of age categories and ethnicity. Older adults like Mrs. R are frequently characterized as young old (65–75 years of age), old old (75–85 years of age), or oldest old (those 85 years of age and greater). The baby boomers (those born between 1946 and 1964) will start turning 65 in 2011, and the number of older people will increase dramatically during the 2010–2030 period. The oldest-old population is the fastest growing segment of the population and is projected to grow rapidly after 2030, when the baby boomers move into this age group. The U.S. Census Bureau projects that the population age 85 and over could grow from 5.3 million in 2006 to nearly 21 million by 2050 (Federal Interagency Forum on Aging-Related Statistics, 2006).

With the expected increase in the number of older adults, there is also an anticipated change in the racial/ethnic composition of this cohort. It is projected that by 2030, more than 1 in 3 older adults will be from 1 of 4 minority groups: African American, Asian/Pacific, Hispanic, and American Indian (Federal Interagency Forum on Aging-Related Statistics, 2010).

Because of the projected increase in the older-adult population, the health and the usage of health care services of this group will be of great concern to public policy. Population information will be needed in order to evaluate their impact on Medicare and Medicaid (Kramarow, Lubitz, Lentzner, & Gorina, 2007). Some states have higher concentrations of older adults and will need to analyze available resources to accommodate the projected rise of this population. Presently, the majority of older adults reside in 10 states: Florida, Pennsylvania, West Virginia, Iowa, North Dakota, Rhode Island, Maine, South Dakota, Arkansas, and Connecticut (Administration on Aging, 2009). Health care resources, transportation options, availability of caregivers, and health policy will all be affected by the increase in the number of older adults.

Life expectancy:

The decline in adult mortality over the past half century has contributed to the steady increase in life expectancy. In 2004, the average life expectancy at birth in the United States was 75.2 and 80.4 for men and women. At age 65, the average male was expected to live another 17.1 years and females another 20 years (Centers for Disease Control and Prevention, 2006). The extended life span of humans is largely due to advances in medical science that have prevented or decreased the occurrence of acute illness. Chronic disease and degenerative illness have replaced acute illness as the leading causes of death for older adults.

How can Mrs. R successfully age without becoming dependent on others for physical support?

Successful aging allows older adults like Mrs. R to maintain autonomy and remain living independently in the community. However, there is a lack of a universal definition or measurement of successful aging. The World Health Organization, the White House Conference on Aging, and the National Institute of Aging have emphasized that successful aging goes beyond avoidance of disease and disability. Rowe and Kahn (1997), whose model was used in the MacArthur Research Network on Successful Aging, defined successful aging as including low probability of disease and disease-related disability, high cognitive and physical functional capacity, and active engagement in life. Other components in the literature identify life satisfaction, presence of illness, longevity, personality, environment, and self-rated health (McReynolds & Rossen, 2004).

Research suggests that ...

Table of contents

• Cover
• Title page
• Copyright page
• Contributors
• Introduction
• Abbreviations and Acronyms
• Section 1: The Aging Population
• Section 2: Common Health Challenges of Aging
• Section 3: Health Promotion
• Section 4: Environments of Care
• Section 5: Cognitive and Psychological Issues in Aging
• Section 6: Issues of Aging and Independence
• Index