NURS 6540: Advanced Practice Care of Frail Elders | Week 9

NURS 6540: Advanced Practice Care of Frail Elders | Week 9

Sometimes a patient’s condition requires an immediate medical response. This was the case for newspaper columnist Steve Lopez. While in post-op after having knee replacement surgery, his heart suddenly stopped for 30 seconds. After surviving this experience, he realized the importance of advance directives. In his column, Lopez (2012) says, “And by all means, folks, get yourself an advance health care directive if you don’t already have one. Whether you die expectedly or unexpectedly, or end up critically ill, you need to make your wishes known about your legal affairs and medical choices.” When caring for patients with needs related to specialized areas of care, life-altering decisions can be made much more quickly when a patient’s wishes are known. In your role as the advanced practice nurse, you are able to convey this message as you often facilitate the discussion of wishes and advanced directives with patients and their families.

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This week, you explore decision making in specialized areas of patient care. Then, you examine the role of advance directives in nursing practice, including how they might benefit patients when making treatment decisions in specialized areas of care. You also explore potential outcomes for frail elder patients receiving these treatments. Finally, you consider the impact of environmental factors on decision making for treatment and interventions.

Learning Objectives

By the end of this week, students will:

• Assess patient outcomes
• Analyze patient care and treatment options
• Evaluate the use of advanced directives in nursing practice*
• Evaluate patient outcomes for frail elders receiving treatment for specialized areas of care*
• Evaluate the impact of environmental factors on decision making for treatment and interventions*

*The Assignment related to this Learning Objective is introduced this week and submitted in Week 11.

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.

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?

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: NURS 6540: Advanced Practice Care of Frail Elders | Week 9

• 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.

By Day 3

Post an explanation of potential outcomes of the patient in the case study you selected. Then, explain how care, treatment, and/or support may be facilitated for the patient. Include how you might address the needs of the patient’s family as well.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days in one or more of the ways listed below. Respond to colleagues who selected a different case study than you did.

• Offer alternative outcomes based on the case study and provided patient information.
• Share additional suggestions for the care, treatment, and/or support for the patients in the case studies your colleagues’ selected.
• Validate an idea with your own experience and additional literature search.NURS 6540: Advanced Practice Care of Frail Elders | Week 9