Week 9 Discussion: Treating Patients in Specialized Areas of Care

Week 9 Discussion: Treating Patients in Specialized Areas of Care

Week 9 Discussion: Treating Patients in Specialized Areas of Care

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

For this Discussion, you examine the following case studies and consider how you might address the needs of the patients and their families. Week 9 Discussion: Treating Patients in Specialized Areas of Care.

Case Study 1

Mr. Wiggins is a 78-year-old African American male with chronic kidney disease, which requires dialysis. The etiology of his renal disease was multifactorial—long-standing uncontrolled HTN and DM nephropathy. He has been on hemodialysis for the past 10 years and has done relatively well. Four weeks ago, he had a major CVA and is minimally responsive. His condition is not expected to change, and the family is having a difficult time with his recent health changes. Advanced directives were discussed with them, and his wife is a durable power of attorney for his health care. The wife hates to see her husband this way and understands this is not how he would want to go on but their children and many of the family members (his brothers and sisters) think the patient will return to himself. They want everything done in terms of life support measures—full code status. His family wanted a feeding tube placed, and he is now receiving 24-hour tube feedings. You are the NP caring for Mr. Wiggins. You have known and cared for him and his wife for several years. The wife pulls you aside, shares her dilemma, and asks you to make the decision regarding continuing medical care/support for her husband. How will you respond? Week 9 Discussion: Treating Patients in Specialized Areas of Care.

Case Study 2

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

Mrs. Adams is in remarkably good health, and other than arthritis and mild HTN, she has no significant medical or surgical history. She is able to carry out all of her essential daily living activities. She pays her own bills, is competent, and has good functional abilities. She was driving up until last year. Now, she has neighbor’s assist with weekly shopping and transportation to church. Her sensory, functional, and cogitative abilities were evaluated this admission and remain intact. She has been offered palliative surgical intervention, but deferred all treatment. Her only son is in agreement with his mother’s decision. Her parents and husband are deceased. You have been asked to obtain advanced directives. What will your discharge treatment plan be for Mrs. Adams?

Case Study 3

Mr. Pierce is an 82-year-old East Indian male, recently widowed 6 months ago. He fractured his left hip 2 months ago attempting to climb his backyard fence to get his cat out of a tree. His children live internationally and have been taking turns caring for him. His eldest son brought him in through the ED last night because Mr. Pierce started having shortness of breath and his lips turned blue. In addition, his son noticed his left leg was very swollen compared to the right. The ED nurse practitioner ordered a thin cut cat scan (CT) with pulmonary embolism (PE) protocol and deep vein thrombosis (DVT) scan Mr. Pierce has a large DVT that is obstructing circulation and multiple pulmonary emboli. His condition is life threatening and he is only expected to live a few weeks. He has a living will and advanced directives and has requested to be able to die in the comfort of his home. “I hate hospitals.” You have been consulted at the patient and family’s request because you are Mr. Pierce’s primary care provider. What additional services can be offered to ensure his care/comfort at home and to give him peace of mind regarding his estate?

To prepare for Week 9 Discussion: Treating Patients in Specialized Areas of Care:

Select one of the three case studies. Reflect on the provided patient information.

Think about potential outcomes for the patient in the case study you selected.

Consider how care, treatment, and/or support might be facilitated for the patient. Reflect on how you might also address the needs of the family. Week 9 Discussion: Treating Patients in Specialized Areas of Care.

NURS 6540 Week 10 Discussion – Community Advocacy Agencies

Having received a diagnosis of Alzheimer’s and encountering the associated stigmas, Michael Ellenbogen encourages increased advocacy efforts for the geriatric population struggling with this disease. He says, “We did nothing wrong to get this disease, and we need to speak up to let our voice be heard…There are no excuses for not wanting to help. The human cost factor is too high, and we are all accountable to do something” (Ellenbogen, 2012). As an advanced practice nurse caring for the geriatric population, it is important for you to join in advocacy efforts within your community whether it is in support of Alzheimer’s or another prevalent need such as abuse. You should be aware of community agencies that advocate for the well-being and care of your local geriatric population, as these agencies often provide resources and assistance to the elderly in need. In your role of care, you are able to identify prevalent needs and work with patients, their families, and agencies to promote change and impact lives.

To prepare:

Review this week’s media presentation, as well as the American Geriatric Society’s Public Policy and Advocacy website in the Learning Resources

Locate and research two agencies that advocate for the elderly in your community. Consider their current advocacy actions and/or campaigns.

Reflect on your experiences and observations at your practicum site. Consider new advocacy actions you might suggest to the agencies you selected. Based on these advocacy actions, think about new policies that might improve the care of the population at your current practicum site.

Post on or before Day 3 a description of two agencies that advocate for the elderly in your community, including their current advocacy actions and/or campaigns. Then, explain new advocacy actions you might suggest to these agencies based on your experiences and observations at your practicum site. With these advocacy actions in mind, suggest at least one new policy that might improve the care of the population at your current practicum site.

Read a selection of your colleagues’ responses.

Respond on or before Day 6 to at least two of your colleagues on two different days who are in different practicum settings than you Explain issues within your own community that might impact the advocacy actions and policies suggested by your colleagues.

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NURS 6540 Week 11 Discussion – Discussing End-of-Life Care

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

—Nancy Kummer, geriatric patient

This human tendency to avoid the unpleasant makes end-of-life care and hospice decisions difficult for many patients to discuss with their families. Kummer is a former social worker who used to counsel patients with terminal illnesses, yet she avoided discussing her own end-of-life wishes with her children. While many Americans like Kummer, agree that these discussions need to take place, few have actually had these conversations with their families (Lazar, 2012). Although initiating conversations about end-of-life care and hospice might be difficult for patients, as an advanced practice nurse, facilitating these conversations is an integral part of your geriatric nursing practice. For this Discussion, consider how you would facilitate care conversations with the patients and families in the following case studies:

Case Study 1:

Mrs. Sloan, a 69-year-old widow, is about to enter the hospital for an elective cholecystectomy; she is being medically cleared by her primary care provider. During the discussion, she requests to be placed on a no code status during her hospitalization. Mrs. Sloan claims that besides her gallbladder problem, her general health status is good. She wishes to have the surgery to avoid any further attacks, which have been very painful. She states, however, that if during surgery or her postoperative period, she undergoes a cardiac arrest, she would prefer not to be resuscitated. She has read about the chances of successful resuscitation, and has determined that the risk of brain damage is too high. For this reason, she is requesting a no code status.

Case Study 2:

Ms. Stearns is an 83-year-old nursing home resident with hypertension, coronary artery disease, arthritis, renal insufficiency, hearing impairment, and a previous history of stroke. She also has a foot deformity from childhood polio. She is disoriented at times. She has lived in the nursing home for 10 years and rarely leaves the chair beside her bed. She has recently developed urinary incontinence, but has refused a bladder catheterization to determine postvoid residual urine or possible bladder infection. She does not have a diagnosis of dementia; however, current testing reveals that she performs poorly on a standardized mental status examination. She can, however, identify all the staff in the nursing home, and she can describe each patient who has been in the bed next to hers over the past 10 years. When asked to explain why she does not want bladder catheterization, she gives several reasons. She states that the incontinence does not bother her and that she has always been a very private person. She particularly dislikes and objects to any examination of her pelvic organs; in fact, she has never had a pelvic examination nor has she ever had sexual intercourse. She realizes that she has a number of medical problems and that any one of them could worsen at any time. She states she is not willing to undergo any treatment for any of her current problems should they become worse.

Case Study 3:

Mr. Marley, age 91, is admitted to the intensive care unit following a stroke. The stroke progressed from mild hemiparesis and difficulty speaking to complete unresponsiveness and an inability to swallow. His daughter feels certain, based on prior explicit conversations with her father, that he would not want to have any treatment that would prolong his life and leave him in a severely disabled state. Mr. Marley’s oldest son disagrees with his sister’s assessment of their father. The son claims that their father still has a strong desire to live, and that he has been very active in his church until this stroke. Because Mr. Marley cannot swallow, he cannot be fed The family is asked about insertion of a feeding tube. It is explained to the family that without food and fluids, their father will die fairly quickly. There are no existing advance directives or a designated health care decision maker noted for Mr. Marley.

To prepare:

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

Reflect on the role of the advanced practice nurse in facilitating the discussion of end-of-life care with patients and their families.

Think about how you, as an advanced practice nurse, would approach a family who wants “everything” done for a patient with only a limited time to live.

Consider when it is appropriate to involve hospice and how to approach patients and/or families who refuse hospice services.

Select one of the three provided case studies related to the end-of-life care of the frail elderly. Reflect on potential patient outcomes and how you would facilitate the discussion of care with this patient’s family.

Post on or before Day 3 an explanation of the role of the advanced practice nurse in facilitating the discussion of end-of-life care with patients and their families. Explain how you would approach a family who wants “everything” done for a patient with only a limited time to live. Then, explain when it is appropriate to involve hospice and how to approach patients and/or families who refuse hospice services. Finally, explain potential outcomes of the patient in the case study you selected and how you would facilitate the discussion of end-of-life care with this patient’s family.

Read a selection of your colleagues’ responses.

Respond on or before Day 6 to at least two of your colleagues on two different days who selected different case studies than you. Based on the site of care, suggest strategies for establishing the role of advanced practice nurses in end-of-life discussions with patients.

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