A Treasure Trove of Educational Resources for Gerontological Nursing (Part 2)

VickyRN, MSN, DNP, RN

The John A. Hartford Foundation was established in 1929 by bequest of its founders, the two brother heirs of the great Atlantic and Pacific Tea Company fortune. The mission of the Hartford Foundation is to "improve health care for older Americans."

The Hartford Institute for geriatric nursing offers the following marvelous Try This resources free of charge to help promote gerontological nursing: the General Assessment Series, the Specialty Practice Series, and the Dementia Series.

In this blog entry we discuss the specialty practice Try This series, six concise assessment guides that are tailored to enhance the care of older adults within specialized practice settings. These free best practice protocols are versatile and easy to use. The assessment tools were developed by nursing specialty organizations in partnership with experts in the field of gerontology. For your convenience, these wonderful resources are highlighted below.

Assessment of nociceptive versus neuropathic pain in older adults

Pain has been described as an unpleasant sensation that may have a lasting emotional and disabling influence on the individual. Nociceptic pain is pain that results from direct tissue injury. Neuropathic pain, on the other hand, is pain that results from damage within the nervous system itself. The abnormal alterations in the nerves often remain long after an original insult has occurred. Sources of acute neuropathic pain may include phantom limb pain after amputation, postmastectomy pain, and pain from nerve compression. Sources of chronic neuropathic pain may include pathological changes in the nerves caused by disease or treatments, such as diabetic neuropathy, chemotherapy-induced neuropathies, neuralgia pain that follows herpes varicella-zoster (shingles), and cancer-related nerve injury.

Pain can significantly affect functionality and quality of life in the older adult. It is very important to distinguish between nociceptive and neuropathic pain, since these two types of pain require different diagnostics and treatment. Two valid and reliable assessment tools that are quick and easy to use in the older adult population to help differentiate nociceptive from neuropathic pain are the LANSS (leeds assessment of neuropathic symptoms and signs) pain scale and the dn4 (doulear neuropathique-neuropathic pain) questionnaire. The LANSS pain scale consists of two parts: a 5-item pain scale and 2 physical exam findings. The dn4 consists of 2 patient interview questions and 2 patient examination questions.

Informal caregivers of older adults at home: let's prepare!

The population is aging and this has led to consideration of the long-term social service and healthcare needs of the elderly and their caregivers. Nearly two-thirds of older Americans aged 65 and above will eventually need long-term care services, which will result in a greater economic burden on society. Within the elderly population, the 85 and older subgroup are most at risk for dependency and consume the largest share of long-term care services. This is a major concern, since the fastest growing segment of the u.s. population is the "old old," persons 85 years and older, who are expected to quadruple in number over the next three decades.

Informal family caregivers provide the bulk of caregiving services for dependent older adults in the community. Often these care needs are complex and the caregivers may not be adequately prepared to manage multiple treatment regimens, recognize early warning signs of infection or possible complications, and coordinate care among a dizzying array of providers. Visiting nurses can use the 'let's prepare' screening tool to evaluate the ability of informal caregivers to safely care for their dependent older relatives at home. 'Prepare' is a mnemonic for the following checklist: prescriptions, readiness to manage at home, early changes in condition, partnership among the home health care team, assistance needed to perform procedures, and realistic expectations and goals.

Cardiac risk assessment of the older cardiovascular patient: The Framingham Global Risk Assessment Tools

The Framingham Heart Study is a long-term, ongoing research study that is now in its third generation of participants. The objective of this study is to identify modifiable and nonmodifiable risk factors that contribute to cardiovascular disease. Modifiable cardiovascular risk factors include physical inactivity, obesity, high blood pressure, abnormal amount of cholesterol and/or fat in the blood, smoking, metabolic syndrome, diabetes, and depressive symptoms. Nonmodifiable risk factors include age, family history, and gender.

Since cardiovascular disease is the leading cause of death in the older adult population, all adults over age 40 should be evaluated for cardiovascular risk. The Framingham Global Risk Assessment tools are an effective way to comprehensively measure cardiovascular risk in older adults.

Vascular risk assessment of the older cardiovascular patient: the Ankle-Brachial Index (ABI)

Vascular disease includes such venous and arterial conditions as hypertension, atherosclerosis, cerebrovascular accident (stroke), carotid stenosis, abdominal aortic aneurysm, and peripheral arterial disease. The Ankle-Brachial index (ABI) is a test that measures the blood pressure in the ankles and compares it to the blood pressure in the arms. This quick, noninvasive test is an effective tool for predicting the severity of peripheral arterial disease. A low ABI signifies atherosclerosis that can lead to circulatory problems in the legs. It also indicates increased risk for heart attack and stroke. It is vitally important to screen for stroke risk, since stroke is the third leading cause of death in the older adult population and a major cause of disability.

To competently assess vascular risk in older adults, a focused physical examination should be performed. Besides the ABI, the physical examination should include vital signs, assessment, palpation, and auscultation of pulses, and identification of signs of poor circulation in extremities such as hair loss, thin shiny skin, and thick brittle nails.

Assessment of spirituality in older adults: FICA Spiritual History Tool

Spirituality is inherent to the human condition, even though some people may eschew religious affiliation or belief in god. Religion and spirituality tend to become more relevant as people age because of increased burden of chronic disease and nearing death awareness. Spiritual beliefs and expressions can be an important source of hope, meaning, and strength to the older adult in times of challenge and crisis. likewise, religious affiliation can provide social support that the older client may desperately need. Although related, religiosity and spirituality are not necessarily synonymous. Religiosity refers to belief in god, standard dogma, human structures, organized ritual, symbolism, and rules. spirituality, on the other hand, is a broader term that encompasses personal understanding of meaning and purpose in life.

Spiritual assessment is an integral part of the comprehensive history of the older adult and provides a basis for the individualized holistic plan of care. The older client should be asked about spiritual concerns or religious practices and made aware of spiritual resources (such as pastoral counseling) that are available to help manage spiritual distress. Unfortunately, the need for spiritual assessment is often overlooked within our fast-paced health care system. Nurses may feel uncomfortable discussing spirituality. They may also feel inadequately prepared to conduct this type of assessment. FICA is an ancronym that can be used to guide assessment of spiritual needs: F (faith or beliefs), I (importance and influence), C (community), and A (address in care). The FICA Spiritual History tool is a quick and easy means to assess both religiosity and spirituality in a sensitive and patient-focused way and then incorporate the findings into routine patient care.

Perioperative assessment of the older adult

Since older adults are the core business of health care, it is not surprising that people aged 65 and above account for 55% of all surgical procedures. the perioperative guidelines address the special needs of older surgical candidates, who often present with multiple complex chronic conditions in addition to the need for late-life surgery. Some operative procedures are emergent, whereas others are elective. Advanced age alone should never preclude consideration for any type of surgical procedure. Often, functionality and quality of life in the older adult can be dramatically improved by surgical intervention. The primary goal of these guidelines is to reduce perioperative mortality and morbidity among the older adult surgical population by: 1) promoting safety, 2) preventing injury, 3) avoiding complications, 4) ensuring optimal functionality, 5) preventing delirium, and 6) providing adequate pain control.

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