Pain remains a common symptom experienced in the palliative care patient population. Despite advances in pain management, patients remain at risk for inadequate relief, especially at end of life (EOL). In order to provide quality pain relief, nurses must possess appropriate knowledge regarding assessment and treatment including pharmacological and nonpharmacological interventions. This chapter provides nurses with a basic overview of the principles of pain assessment and pharmacological management throughout the illness continuum and at EOL. The needs of special populations who have been identified as “at risk” of inadequate pain control are highlighted, including older adults, children, persons with communication impairment, patients with a history of substance abuse, and cancer survivors. These groups represent those in whom pain is often unrecognized, not respected or not believed. Many of the principles of pain assessment and management reviewed can be applied to children.
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An adult is presumed to have the ability to make his or her own healthcare decisions—including termination of life-sustaining technology—unless he or she is shown to be incapacitated by clinical examination or ruled incompetent by a court of law. Advance care directives are legal vehicles used by people to provide guidance to their healthcare providers concerning the care they would desire in the event they become incapacitated and cannot make their own decisions. Problems with advance directives may arise when they do not seem to apply to the patient’s situation. Nurses roles include educating the patient and family about the patient’s condition and legal end-of-life (EOL) choices, identifying the patient’s and family’s wishes for EOL care, articulating the patient’s and family’s desires to other members of the healthcare team, and assisting the patient and family to obtain necessary and appropriate EOL care.
Career opportunities are projected to grow faster for nursing than all other occupations through 2026. The advantage of a career framework with multiple stages is that one doesn’t start out expecting to be fully developed at the beginning. Mentoring is needed throughout a career, not just at the start. This chapter provides an overview of the career model that the author has fleshed out over time, greatly influenced by Dalton, Thompson, and Price’s classic article (1977) on stages of a professional career and subsequent work. There are five career stages whereby the individual moves from: (a) becoming prepared, to (b) demonstrating the ability to work independently and interdependently in achieving professional goals, then (c) developing others and the home institution, then (d) advancing the profession and healthcare, and eventually (e) daring to be a truth teller. Exerting leadership presupposes complete career development, going through all five career stages.
The main message of this chapter is that a professional career requires sustained development in interpersonal, interprofessional, and communication effectiveness. Undergraduate and graduate courses are full of valuable information about communication—spoken, written, visual, electronic, and social media. Instead of trying to summarize the communication essentials that nurse leaders should have acquired along the way and will need to develop additionally over time, this chapter focuses on some communication skills important to goal achievement that the author learned to appreciate more with experience. They fall under the following headings: courtesies, self-presentation, negotiations, the importance of data arrays and publication, and the value of understanding the viewpoint of others. Self-monitoring, as a leadership ability, means the person seeks to shape how she or he is perceived in order to achieve professional objectives. Measurable outcomes and published results are important in building the image of the profession.
Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States and the leading cause of death due to a respiratory cause. Development of this disease occurs as the result of cigarette smoking and exposure to environmental pollution. In addition, the normal physiologic changes due to the aging process place individuals at an increased risk for the development of complications, such as cor pulmonale and pneumonia. In order to reduce the risk of developing the complications of COPD, smoking cessation is recommended. Pharmacologic modalities focus on improving ventilation, reducing inflammation, and preventing complications. Nonpharmacologic interventions including exercise, rest, and improved nutrition can be valuable complementary therapies in the care of patients with COPD. To provide palliative care for patients at every stage of COPD, from diagnosis to the end of life, the nurse needs to acquire the knowledge and skills for expert nursing care.
Gastrointestinal (GI) symptomatology is common in patients receiving palliative care. Many patients have described the constant nausea, vomiting, and diarrhea as more disabling and disturbing than pain. Anorexia and subsequent cachexia are common in patients at the end of life with multiple potential and often overlapping causes. GI symptoms affect patients’ activities of daily living and influence their quality of life. Other common GI symptoms in palliative care patients include dysphagia, constipation and bowel obstructions, hiccups, and xerostomia. All of the GI symptoms may be related to the pathology of the diseases as well as treatments. Having an understanding of both is crucial for the nurse caring for patients in this setting. As in all palliative care, ongoing assessment of the patient is necessary to determine what interventions are working and which need modification. Interventions include pharmacological, nonpharmacological, and complementary therapies.
Strategic planning involves examining how your professional and/or organizational mission is being affected by changing circumstances, setting goals with concrete actions and a timeline, and then figuring out needed resources and expected outcomes. “The vision thing” at its best involves periodically embarking on a process of strategic planning whereby you examine how your professional or organizational mission is being affected by changing circumstances, and then set short-term and long-term goals with concrete actions and a timeline that moves you in desired new directions. Transformational leaders are deeply committed to the organization and its mission/values, make use of consultants so that they are not limited by the boundaries of their expertise, are willing to try something new knowing that not all good ideas work out, combine vision with practicality in figuring out how to operationalize the change process, and know how to use a range of individuals to the organization’s advantage.
This chapter discusses several common skin problems including skin tears, pressure injuries formerly known as pressure ulcers, skin tumors, treatment-related skin injuries, peristomal skin, and fistulas. Skin changes, including pressure injuries, are common occurrences during the dying process. The Wound Bed Preparation 2015 model can be used as a clinician guide to develop a care plan for a palliative care patient with an alteration in skin integrity. Focusing on the wound etiology and classifying wounds as healable, maintenance, or palliative (non-healable) can provide realistic expectations for patients, their family unit, and caregivers as well as the healthcare professional team. Wound care should be aimed at improving the patient’s quality of life by providing comfort, relieving pain, controlling odor, and containing exudate. It is paramount that the patient’s preference be prioritized in the decision-making process and the implementation of realistic treatment care plans.
This chapter focus is on sexual health. Sexual health is a broad concept made up of multiple facets such as sexual desire, self as a sexual being, sexual orientation, sexual lifestyles, and relationships. Intimacy, closeness, communication, and emotional support affect all facets of sexuality. Sexual health within the context of palliative care may be directly impacted by the disease on anatomical structures. However, direct anatomical effect is not the only concern; changes in a person’s sexual interest or desire may also be affected by direct or indirect consequences of medical treatment or in association with being terminally ill. Illness involving sexual organs increases the likelihood of retraumatization for those who have experienced previous sexual trauma. Healthcare practitioners (HCPs) frequently avoid talking about sexuality with cancer patients. HCPs’ barriers to discussing sexuality include embarrassment, misinformed beliefs and assumptions, lack of knowledge, inadequate communication skills, and time constraints.
Neediness cannot be banished, but it’s possible to learn from each shortcoming, determined not to be derailed by either hubris or core anxieties. Taking on new leadership roles, we have to get in touch with warring expectations on the way to a more textured view of leadership and our sense of ourselves as leaders. There are a number of normal-crazy thoughts that get in the way of leadership; for example, wanting to be liked by everyone; believing that if you’re not perfect then you’re no good; thinking things should not go wrong. To succeed, nurses must realize that failure is commonplace. Expect failure, recognize root causes, and then proceed to learn from the experience—this process builds personal resilience. Learning environments that foster a culture of potentiality enable fledgling practitioners to persist in the face of failure because the emphasis is on improving over time.
The principles of hospice care embrace holistic patient- and family-centered care, offered by an interprofessional team of practitioners. Built on the foundation of hospice care, palliative care (PC) addresses care of the mind, body, and spirit as health practitioners develop the most effective and appropriate plan of care for and with patients and families experiencing serious, life-threatening, progressive, or chronic illnesses. As a new paradigm of healthcare, PC is responsive to the need for healthcare reform in America and globally. This chapter presents an exemplary palliative care action plan developed in the state of Maryland. In both generalist and specialist roles in palliative and hospice care, nurses are leaders of healthcare reform in the United States as they combine knowledge, experience, and commitment to advancing the specialty and promoting quality palliative and end-of-life care. The chapter discusses the roles of advanced practice palliative care nurses.
Since ancient times, self-knowledge has been regarded as the key to effective leadership. No nurse is good at all aspects of nursing; therefore, each nurse needs to figure out what will be her or his area of special contributions. Instead of focusing largely on weaknesses, organizations should identify their employees’ strengths for the purpose of using them strategically and then managing to those strengths. It is better to admit one’s limitations early on, and deal with them, rather than spend years trying to hide them. No one really likes criticism, but criticism is the lifeblood of professional development and improvement; therefore, leaders need to know how to give and accept criticism in an ego-enhancing way. Self-knowledge is never complete; it is achieved through ongoing introspection, candor, figuring ourselves out in different situations, and looking at ourselves through the eyes of others.
Retirement isn’t a single event, but a process that varies in when it happens and how long it takes before the person adjusts to a new way of life. Planning for retirement should include developing financial literacy at the start of a career so earnings and savings are smartly invested; preparing for the time by figuring out how to structure newfound freedom; not stopping all work abruptly but providing for some period of transition; beginning to take on more activities that one prefers to do rather than what one has to do; and giving some thought to facilitating a smooth relationship with successors. Both those letting go and those coming on occupy different psychological and generational space, and their differences in perspective are normal. One’s perspective is no more right than the other’s, but they are viewing matters through different lenses, setting the stage for potential misunderstandings.
Health-promoting palliative care (HPPC) emerged in the 1990s as a concept that proposes that even in the event of advancing disease, a person can maintain a sense of health and wellness. The provision of palliative and end-of-life (EOL) care does not preclude interventions that optimize health, well-being, and functional status even in the presence of incurable illness. The application of the principles and practices of health promotion to palliative and EOL care enhances the health and well-being of individual, families, and communities. Health promotion and rehabilitation are critical to maximizing an individual’s function and well-being even in the face of life-threatening illness. Rehabilitation is a valid intervention in advanced disease, promoting optimal function and mitigating deficits in activities of daily living, well-being, and quality of life (QOL). The role of the nurse in rehabilitation is vital in responding to the complex needs of those with advanced disease.
There is a high likelihood that anyone who is receiving palliative care has been exposed to a traumatic event during his or her life that may place him or her at risk of posttraumatic stress disorder (PTSD). This chapter provides the reader with an overview of PTSD and evidence-based treatments within a palliative care setting. The criteria for PTSD are outlined along with a description of appropriate approaches to assessment. Currently available evidence-based treatments are described and illustrated with case examples. The importance of addressing PTSD in end-of-life (EOL) care for both the individual and family is highlighted. The chapter also highlights the importance of assessing for specific mental health disorders such as PTSD in order to allow both the individual and his or her family to receive state-of-the-art EOL care. PTSD can negatively impact patient–provider communication and lead to increased psychological distress at the end of life.
Patients and families facing a life-threatening illness have needs that are best addressed through an interprofessional palliative care team model. An effective interprofessional team will attend to these particular needs and will include specialists as warranted by the distinctive illness and needs of the patient and family. With a comprehensive palliative care program, the interprofessional team works with the patient and family in a coordinated and collaborative manner to achieve mutually established goals. A dynamic and outcome-oriented interprofessional team requires collaboration, leadership, coordinated decision making, and conflict resolution. Interprofessional palliative care teams ideally consist of a team leader (usually the advanced nurse practitioner or the physician), nurses, social workers, and chaplain. Interprofessional education is key to developing a workforce of the future that will provide comprehensive, compassionate, cost-effective, continuous, and evidence-based healthcare for varying patient populations, families, and communities.
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Communicating With Seriously Ill and Dying Patients, Their Families, and Their Healthcare Practitioners
When nurses communicate with their dying patients and the patients’ families, they have a clearer understanding of their patients’ needs and goals at the end of life. This chapter explores ways to encourage both nursing students and graduate nurses to facilitate communication with dying patients, their families, and their healthcare providers. It also explores ways in which nursing faculty members might assist undergraduate nursing students to enrich themselves by working with dying patients. The chapter is organized according to the phases of the therapeutic relationship because in many ways the phases of the therapeutic relationship—introductory, working, and termination—parallel the dying trajectory. When appropriate in the phases, distinctions are made between the roles and educational needs of the undergraduate nursing student, the nurse with an undergraduate degree, and the nurse with an advanced practice degree.
Palliative care (PC) and hospice nursing reflects a holistic philosophy of care implemented across the life span and diverse health settings. PC and hospice nurses relieve suffering along the course of illness, through the death of the patient, and into the bereavement period of the family. This chapter presents an evolutionary perspective of hospice and palliative care nursing. The standards of practice in PC and hospice nursing describe a competent level of generalist and advanced practice registered nursing care as demonstrated by the nursing process. The standards of professional performance require the integration of specific core competencies aimed at ensuring the delivery of safe, quality patient-centered care, including the demonstration of competent professional role behaviors in practice, education, research, and leadership. PC nurses collaborate with all members of the interprofessional team, to insure quality and continuity of care in meeting the needs of patients and their families.
Heart failure (HF) is a terminal disease. Predicting the illness trajectory is much harder in HF than in cancer. Nursing has a key role in the management and outcomes of patients with HF. Patients often turn to nurses for information on their disease especially in the end stages of the disease. A coordinated effort by nursing has been developed as to how to help patients with not only the physical symptoms of HF but also the psychosocial aspects. In caring for the patient with advanced HF, there are clinical, evidence-based therapies that should drive clinical decision making. This chapter helps the reader to understand the disease of HF: how important disease management is, how nurse-based HF interventions can lead to positive outcomes, and, most importantly, how to communicate with patients and families regarding their treatment options and what is important to them in the final phase of their life.
When one thinks of the lofty qualities that leaders are supposed to have, one thinks of high-powered ones such as integrity, creativity, courage, and intelligence. Nurses don’t think of sustaining optimism and managing anger, because they seem more like givens than a stretch toward greatness. However, one of the most difficult but important aspects of leadership from the personal side is to take responsibility for managing our well-being so that one can stay optimistic enough to energize others. Managing anger is a part of sustaining optimism, but so are many other things. Sustaining optimism is inextricably connected to taking care of oneself. Anger can have benefits when it provides motivation for realistic confrontation of a problem. Body listening is an important part of self-regulation; the better one gets at figuring out one’s own energy fluctuations, the more likely one can use them to advantage.
This chapter focuses on leadership as transformational. Transformational leadership means moving a profession, an institution, or some aspect of healthcare down a new path with different expectations, structures, and ways of conceptualizing how the mission can be achieved in light of changing conditions. Looking back on all that nursing has achieved in the last half century can be energizing; it makes trying to do something different yourself not seem quite as daunting. Nursing is much stronger now as a profession than it has been in the past—larger, better educated, somewhat more diverse with a solid infrastructure, demonstrated outcomes, specialty expertise, a growing research base, more opportunities, and no longer time and place bound. Nursing’s commitment to the optimization of health and ability, alleviation of suffering, and advocacy hasn’t changed over time; values endure, but how they get expressed will vary as new sensibilities and knowledge become available.
“Doing good” is the prime directive of health profession education, but everyone doing her or his personal best is no guarantee that excellence will prevail. Building clusters of excellence, one can get more productivity as resources are shared and people play off of each other’s ideas, positioning all concerned more effectively to seize new opportunities. Excellence is a “stretch” goal, but if everyone stretches a little, the shape and quality of the organization can be transformed. Even if one achieves only a small portion of what one wanted to accomplish in the name of excellence, this improvement can be just the upstream redirection needed to achieve something even more substantive downstream. Excellence is a journey full of next steps that can only be seen as you move forward and are able to catch a glimpse of what is now on the changing horizon.
Holism focuses on unity, mutuality, meaning, and the interrelationship of all beings, events, and things. Holism is the theoretical and philosophical foundation for all complementary integrative healing modalities. Holistic integrative therapies can be used by the nurse, client/patient, and family. This chapter introduces the reader to a variety of holistic modalities that are used in nursing practice today and can be used in palliative care. It should be noted that centering, relaxation, imagery, meditation, reminiscence and life review, and journal writing are basic and can be practiced by nurses and students with little or no experience. The sense therapies, touch therapies, and Reiki body work necessitate further study. Whenever one learns these therapies, it is imperative that nurses practicing in palliative and hospice care be familiar with healing modalities and their beneficial effects for patients and families during the illness experience.
The diagnosis of end-stage renal disease (ESRD) can be difficult for patients and families to hear because this means they will need some form of kidney replacement therapy to survive (hemodialysis, peritoneal dialysis, transplantation). ESRD means a patient has severe end-organ kidney damage and failure. When confronted with the extensive list of medical and psychological problems often associated with patients with ESRD, healthcare professionals often focus on treating the medical issues by implementing strategies to address abnormal laboratory values and treating comorbid conditions. The goal for patients with ESRD cannot be simply to preserve life but also to promote quality of life. This chapter discusses palliative care in relation to three groups of patients with ESRD: undergoing dialysis, choosing conservative management, and withdrawing from dialysis. It also provides a brief review of the major comorbidities and complications associated with ESRD and available palliative treatment options.
Family is a cultural, legal, sociological, and individually defined concept. Family definitions can be discussed in terms of structure, function, and symbolism and family is whoever the patient says it is. A family caregiver is a member of this family who has chosen or who has been designated as the caregiver for one or more family members who cannot manage normal activities of daily living without help. The caregiving role begins immediately at the point of diagnosis and continues over the illness trajectory. Although many studies indicate many negative health outcomes related to family caregiving, there are also benefits to the caregiving role. Theoretical frameworks related to family caregiving can guide questions for family assessment and the development of family caregiver interventions. The needs and concerns of family caregivers should be addressed by all members of the interprofessional palliative or hospice care team.
This chapter focuses on management of people with stroke, chronic neurological disorders (CNDs), coma, and brain death. It presents a description of common symptoms experienced from stroke and CNDs, including Alzheimer’s disease, and related disorders, Parkinson’s disease, multiple sclerosis (MS), and amyotrophic lateral sclerosis (ALS). Comorbid conditions that frequently accompany the latter stages of these illnesses are described as well as interventions aimed to provide symptom management. Common problems faced by patients with these disorders include impairments in cognition, communication, sleep, swallowing, breathing, and mobility, as well as pain, fatigue, and depression. Issues unique to pediatric coma and brain death are also discussed. A growing body of evidence supports that symptoms associated with severe stroke and chronic neurological disorders are amenable to palliative treatment and that quality of life is increased from multidisciplinary approaches to care.
This chapter focuses on diversity and inclusion not as an administrative problem but as a leadership concern. Diversity and inclusion aren’t so much regarded as important in avoiding conflict and difficulties, but as crucial in fostering innovation and creativity. When people come together to solve problems or improve processes, they bring different sentiments, information, and view points. This makes sense when we talk about diversity of disciplinary backgrounds—think about the growing importance of interdisciplinary teams to healthcare education, practice, and research. Embracing diversity can be a competitive advantage for an organization because it is associated with creativity and innovation, but highlighting diversity can lead to suspicion and conflict, and leadership requires balancing these tensions. Developing an inclusive environment implies a respectful appreciation of individual attributes as you forge a sense of belonging and trust, with equitable access to opportunity and reward/recognition.
It has been said that working in interdisciplinary teams is a core competency all health professionals will need in the 21st century; they need to be able to collaborate, coordinate, and, most of all, communicate with one another in order to optimize care and maximize operational excellence. Nurses need to be active in interdisciplinary organizations from the start of their careers, and present/publish their work in interprofessional forums. Nurses have many advantages in interdisciplinary collaboration—sound basic education in humanities, social sciences, and basic sciences; many community connections; and experience in facilitating care across different providers. Interdisciplinary opportunities provide more prospects for effecting large-scale change than discipline-specific opportunities do. Moving beyond the discipline specific doesn’t mean that nurses leave nursing; it means they assume positions in which they can now advance the perspective of nursing in ways that others can appreciate, while attracting additional public support.
Anxiety, depression, and delirium are common symptoms experienced by patients with serious illness. In palliative care, anxiety and depression commonly arise from fear of death, loss of independence, fear of being a burden to others, hopelessness, and loneliness, in addition to concern about symptom burden and disease progression. Anxiety manifests itself in four ways: physical symptoms, affective symptoms, behavioral responses, and cognitive responses. The patient and the family should be reassured that symptoms of depression and anxiety are effectively treated most of the time with pharmacological and nonpharmacological interventions. Effective treatment of anxiety, depression, and delirium necessitates a collaborative effort between the patient, family, and the health team. This chapter addresses the comprehensive patient-centered and family-focused care necessary for effective diagnosis, assessment, and treatment of anxiety, depression, and delirium in the palliative care patient.
After completing the data collection process and reviewing the personal and family history, including pertinent tests and findings from the physical examination, all data should be synthesized and reviewed for red flags that are suspect for disease risk. The review may indicate frequent family members with chronic disease, which indicates a familial propensity or disease risk for the individual; alternatively, the reviewed data may be suspect for an inherited disease or genetic predisposition. This chapter discusses red flags in the family history that may be suspect for a genetic predisposition to disease and describes limitations in the family history regarding some genetic disorders. The family history is an important part of the genomic risk assessment, as it provides essential information that may aid in identifying at-risk individuals for genetic disorders/syndromes or familial diseases.
Once the data are assessed for elements of risk, or red flags, further evaluation should be conducted based on the identified risks to determine risk probability or empiric risk. Risk probability can be focused on the genetic risk based on the probability or likelihood for an inherited disease or syndrome or assessed for empiric risk regarding the chance of disease for noninherited diseases. This chapter differentiates between risk probability and empiric risk, describes measures of determining risk probability as part of the genomic risk assessment and states evidence-based models that can be used as empiric risk models. Careful review of personal and family history data is an important part of the risk-assessment process to determine if red flags exist that may be suggestive of an inherited disorder or syndrome. The use of empiric and/or risk-probability models, when available, may also aid in the risk-assessment process.
Genetics is the primary cause or plays an important role in many medical conditions and birth defects. Given that approximately 3" of newborns have a birth defect or genetic condition, many more develop significant conditions after birth, and more and more women with genetic conditions are having children, medical genetics is of prime importance in obstetric care. This chapter describes how RISK elements can be used when providing a genetic/genomic risk assessment for preconception care (PCC). It discusses ancillary and laboratory measures in obstetrics that are used as part of the genetic risk assessment for screening and diagnosis of the fetus. The risk-assessment process is important in preconception counseling and prenatal care. An important part of the process is a thorough personal and family history. Advanced practice registered nurses (APRNs) should be knowledgeable as to how the risk-assessment process impacts maternal and fetal well-being and the potential for genetic conditions.
According to the National Institute on Aging (2019), hundreds of thousands of adults over the age of 60 are abused each year. Elder abuse is often under the umbrella of elder mistreatment, which includes abuse, neglect, and exploitation among individuals aged 65 or older. This chapter describes risk factors, types of elder abuse, and approaches for prevention and treatment. Advanced practice nurses must be prepared to report as mandated by law, be advocates for prevention and treatment while meeting the needs of elderly patients to ensure quality care. Elder abuse is defined as an act or lack of an appropriate action that results in harm or distress to an older person. The chapter helps the practitioners to: recognize signs and symptoms of elder abuse; summarize laws pertinent to elder abuse; describe factors that contribute to elder abuse; and identify how to respond to needs related to elder abuse.
Sleep disruption is a common occurrence for adults, with insomnia symptoms reported by as many as 33% to 50% of adults. This chapter reviews common sleep-wake disorders encountered in the geriatric population. Practitioners will initially learn about normal, basic sleep architecture before being introduced to some of the commonly encountered abnormal sleep issues constituting sleep-wake disorders. The chapter review tools that can be used to assess sleep and appropriate interprofessional collaboration and referrals. The goal of treatment of sleep disorders should be improved quality and quantity of sleep. The chapter helps the practitioners to: identify the basic physiological states of sleep; understand the importance of an electroencephalogram in sleep disorders; define insomnia disorder and the associated diagnostic criteria; identify differences between insomnia disorders and obstructive sleep apneas; identify how histamine and melatonin receptors work in sleep disorders; and evaluate the use of common sleep aids in geriatric mental health patients.
The ability to reduce the burden of illness among older adults is necessary as individuals are living longer and experiencing lower rates of disability. Advanced practice nurses are skilled to relieve the burden of illness among older adults through specialized training and providing treatment in a variety of clinical settings. While geriatric-focused content exists, advanced practice nurses can benefit from clinical pearls specific for the advanced practice nurse providing holistic mental health care. This handbook offers advanced practice nurses, nurse educators, and graduate nursing students a reference that is intended to be supplemental to uniquely providing care for older adults which includes an overview of the aging process as well as assessing and developing treatment plans for older adults with mental health disorders. As older adults often work collaboratively with family, friends, caregivers, and health care providers, approaches to such relationships are explored and intended to serve as a resource for providing mental health care that can contribute to the overall success of treatment. The text provides an interprofessional box that encourages and assists the advanced practice nurse navigating through interdisciplinary collaborative practice. Such interprofessional partnerships can enhance care—particularly in cases of complexity. Advanced practice nurses can utilize the provided case studies to identify and modify service delivery that promotes evidence based practice.
The end of life can have so many meanings for various cultures. Moments that lead to the end of life are of particular importance as during the process, longstanding effects as well as impressions on family and friends will continue after the patient’s death. Considering all of the factors that can correspond with end of life care, advanced practice nurses should reflect on how to best help patients and their families during this crucial time. While describing end of life care, it is important to distinguish that end of life care is not synonymous with palliative care. This chapter describes the goals, management of symptoms, and needs while providing palliative and end of life care for the elderly within the realm of mental health care. It discusses the ethical considerations of providing geriatric palliative care, and explains differences between end of life care and palliative care.
Definitions of aging continue to evolve. This chapter considers aging a part of normal life processes which consists of the acquisition of knowledge and skills over time, the honing and maximizing of these traits and eventually the time period in which all body systems decline from maximal functioning capacity. It reviews normal aging processes in addition to factors which can affect life longevity such as genetic and environmental factors and the human response to environmental stressors. The chapter also presents a brief review of healthy aging and holistic measures. After reviewing the chapter, practitioners will be able to: define aging, longevity and life expectancy; recognize factors that may impact longevity; summarize major normal age-related physiological and psychosocial changes in humans; explain domains that may promote healthy aging; and discuss the importance of the Annual Wellness Visit in supporting healthy aging.
Geriatric depression or late-life depression is a complex mood disorder that can comprise of various etiological pathways and often occurs in the context of medical illness or cognitive decline. Major depressive disorder (
MDD) is one of the most commonly diagnosed mental illnesses in older adults and is often underrecognized and undertreated. Depressive symptoms are frequently associated with the normal aging process because depression in older adults may be disregarded as frailty, irritability, agitation, or helplessness; therefore, the need to seek medical attention is often overlooked. After reviewing this chapter, practitioners will be able to: describe the prevalence, risk factors, and protective factors for older adults with depression; differentiate between MDDand other mood disorders; discuss example screening tools to help screen older adults for depression and suicide risk; describe evidence-based general pharmacological and nonpharmacological treatment options for depression in older adults; and identify barriers and facilitators to promote treatment compliance.
Geriatric psychiatric care in today’s world requires comprehensive and astute participation among healthcare providers as older adults are living longer - some with complex co-occurring chronic medical conditions. The emphasis in healthcare provided is on outcomes and quality care. Advanced practice nurses have the distinguishing ability to provide care that incorporates undergraduate nursing experiences, advanced education in pharmacology, and pathophysiology. This chapter highlights medication issues and offers guidance for prescribing for geriatric populations across health care settings. Advanced practice nurses must have a clear understanding of their role, methods for assessing issues, and an evaluation of needs to provide high quality care. The chapter helps the practitioners to recognize methods to assess medication issues when prescribing for the older adult; identify contributing factors to medication issues; summarize common black box warning(s) of medications for elderly patients; and initiate ways to decrease medication issues and prescribing in the older adult.
As patients grow older, the incidence of sexual dysfunction increases while sexual activity decreases. Multiple factors contribute to sexual problems, and older age compounds and complicates those factors. Although sexual activity can diminish with age, it helps to acknowledge that more than half of older adults are sexually active. Further, the majority of men and women over the age of 65 report an interest in sex. This chapter helps the practitioners to: define sexuality and sexual dysfunction; distinguish differences in impotence and erectile dysfunction; explain the hormonal changes in aging adult women; apply principles of interdisciplinary collaboration to clinical practice; and identify risk factors genito-pelvic pain/penetration disorder, orgasmic disorder and female sexual interest/arousal disorder. It also helps to recommend evidence-based practice interventions to older adults suffering from reproductive changes; establish a differential for erectile dysfunction in the aging male; and explain options for medical management and treatment of erectile dysfunction.
This chapter introduces the practitioners to substance use disorders in geropsychiatric populations, identifying criteria for diagnosis, assessments and evaluating co-morbidities, including differential diagnoses and indications for treatment options. It discusses the differences in addiction, dependence, tolerance, intoxication, substance withdrawal and treatment options for geropsychiatric populations. The chapter presents a case study with differential diagnoses and risk factors for comorbidities. It discusses substance use disorder assessment tools including evidence based treatment options. Treatment options are dependent on the screening, diagnosis and assessment of the substance, psychosocial stressors and dual diagnosed psychiatric disorder. The chapter helps the practitioners to: identify diagnostic criterion for substance use disorders; analyze specific assessments for Alcohol Use Disorder, Benzodiazepine Use Disorder and Opioid Use Disorder; apply assessment tools and evaluate differential diagnoses to identify substance use disorders; evaluate risks and comorbidities of geropsychiatric populations with substance use disorders; and understand treatment options for substance use disorders.
This chapter introduces the practitioners to the psychiatric evaluation, in general, and specifically for geriatric mental health patients. Practitioners will learn about the essential components of an initial evaluation and review some of the basic methods for assessment such as rating scales and standardized assessment tools. The chapter considers common factors that practitioners may be confronted with specifically in a geriatric psychiatric evaluation. Common confounding and unique issues present during an initial psychiatric evaluation with geriatric patients should be appropriately documented. The chapter provides a general outline for the initial evaluation. After reviewing this chapter, practitioners will be able to: identify the essential components of an initial psychiatric evaluation; discuss unique components and requirements of an initial evaluation with geriatric mental health patients; and evaluate the results/outcome from the completion of an initial psychiatric exam to formulate an appropriate plan of treatment.
Family dynamics for the elderly patient are essential to better understanding the many components that can impede or enhance care. As an advanced practice nurse, considerations for family dynamics adds to an overall holistic approach to treatment that is often what differentiates nursing care. First, assessing the level of independence or what has changed in the management of the older adult’s day to day activities is vital. Secondly, family roles could interfere with the manner in which future affairs are handled, such as the plan of care differing from what a health care surrogate or medical power of attorney would want to see happen. Thirdly, family dynamics could vary widely by culture which could also impact the plan of care for the older adult. This chapter highlights how different factors related to family dynamics could impact care and how advanced practice nurses could approach care in such instances.
Bipolar disorders affect 2.5 million adults in the Unites States annually and approximately 6 million Americans have a bipolar spectrum disorder and 1 million are age 60 or older. Bipolar mood disorders are the sixth leading cause of disability worldwide. This chapter introduces practitioners to bipolar spectrum mood disorders, etiology, prevalence and comorbidities. In addition, it discusses the differences in bipolar 1, bipolar 2, cyclothymic disorders, and bipolar mixed episodes. The chapter presents a case study with differential diagnoses and risk factors for comorbidities. It discusses mood disorder assessment tools including evidence based treatment options. After reviewing this chapter, practitioners will be able to: identify diagnostic criterion for bipolar spectrum disorders; analyze unique differences in bipolar spectrum disorders; apply assessment tools and differential diagnosis to support bipolar diagnosis; evaluate risks and comorbidities of geropsychiatric populations with bipolar disorders; and understand treatment options for geropsychiatric populations with bipolar disorder.
Schizophrenia is a chronic, costly, and vast (across age groups) mental illness that has a prevalence of less than 1 percent worldwide with the average potential of life lost as 28.5 years. A small proportion of older adults experience an onset of schizophrenia after the age of 65, which is rare. Distinguishing whether an older adult has developed late-onset schizophrenia, a medical condition manifesting symptoms as psychosis, or a continuation of underlying schizophrenia symptoms are all integral components to assessment and diagnosis. This chapter discusses the assessment and treatment of schizophrenia spectrum disorders in geriatric patients. It helps the practitioners to recognize characteristics associated with dementia with lewy bodies, early-onset and late-onset schizophrenia; identify risk factors for schizophrenia; summarize treatment options for schizophrenia; and initiate a treatment plan that incorporates the nursing process of assessment, planning, implementation, and evaluation for with schizophrenia and other psychotic disorders.
Later life anxiety is often found in conjunction with major depressive disorders, and can have foundations in dietary issues as well as drug associations. There has been a correlation between long-term presence of anxiety in older adults associated with female gender, lower level of educational achievement, being unmarried as well as having three or more co-morbid chronic conditions. The most common diagnosed anxiety disorder in the geriatric population is generalized anxiety disorder. Other anxiety disorders frequently encountered in practice include social phobia, agoraphobia, panic disorder, post-traumatic stress disorder and obsessive-compulsive disorder. This chapter briefly outlines and discusses each disorder. It helps the practitioners to: define anxiety; distinguish between anxiety disorders; discuss example tools that can be used to establish an anxiety disorder diagnosis; assess a geriatric patient for post-traumatic stress disorder using an appropriate clinical rating scale; and recommend general pharmacological (class) and non-pharmacological treatment options for anxiety disorders.
- Go to chapter: Step 1.a: Review Collected Data—Personal, Ancillary, Laboratory, and Physical Examination
Step 1 of the genetic/genomic risk assessment process requires data collection through history-taking, physical examination, and review and interpretation of additional data (e.g., radiology, laboratory), if applicable. Data collection is an ongoing process that begins at the first clinic visit and then is updated through subsequent health provider and patient encounters. This chapter describes Step 1.a of the genetic/genomic risk assessment and discusses how the physical examination may aid in identifying certain genetic conditions. This chapter introduces the risk-assessment process. The process is an important part of identifying individuals who may be at risk for inherited, familial, multi-factorial, or behavioral disorders. The first step of the risk-assessment process is a thorough review of personal and family history as well as evaluation of physical findings, laboratory data, and other ancillary data if available.
- Go to chapter: Step 1.b: Review Collected Data—Family History and the Use and Interpretation of the Pedigree
The family history is a continuation of Step 1 of data collection for the genomic risk assessment. Family history represents the health and disease conditions experienced by family members over the course of their lives. It is the family tree. The use of a pedigree to capture the family history provides a visualization of the maternal and paternal lineages of multiple generations that can provide an excellent way to observe relationships and patterns that can be suspect or diagnostic of inherited disorders and familial diseases associated with complex chronic disorders or shared environmental issues. In fact, the family history is considered by some as the first genetic test. This chapter discusses common terms used in constructing a pedigree and describes basic elements of the pedigree. Obtaining an in-depth family history, which includes a minimum of a three-generation pedigree, is an important step in the risk-assessment process.