- Email: [email protected]
Exemplars in advanced practice gerontological nursing: A GAPNA Series – GAPNA Consensus Statement Proficiency 7 – Case 7
Geriatric Nursing 38 (2017) 80e82
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
GAPNA Section
Exemplars in advanced practice gerontological nursing: A GAPNA Series e GAPNA Consensus Statement Proficiency 7 e Case 7 Deborah Dunn, EdD, MSN, GNP-BC, ACNS-BC Graduate School, Madonna University, Livonia, MI, USA
APRN Gerontological Specialist Proficiency Statement 7 The APRN Gerontological Specialist is proficient in coordination and management of timely palliative and end-of-life care congruent with the goals and values of older adults and families/ carers. The APRN Gerontological Specialist provides the full scope of care from preventive to curative to palliative and end-of-life care. Through the application of exquisite holistic and multidimensional assessment skills, the Gerontological Specialist identifies progressive life-limiting illness and works to develop plans of care congruent with the goals and values of older adults, and their family/carers to reduce distress and increase comfort.1
and works with the interprofessional team to coordinate timely palliative and end-of-life care with older adults and their families/ carers.5 The importance of accurate prognostication about life expectancy, truth-telling and early disclosure cannot be stressed enough in the discussion of appropriate care of persons with end-stage or life-limiting illness. Quality of life can be enhanced when patients and families have time to set goals, and consider what type of endof-life care they desire. Entering palliative care earlier may actually improve quality of life through reductions in hospitalization, medical interventions, intensive care services and limiting unnecessary suffering.
Overview
Case 7: Margaret Delaney
This case is presented as the seventh in a series of case illustrations developed to provide clinical examples of the application of GAPNA’s APRN Gerontological Specialist Proficiencies. This case highlights GAPNA’s Consensus Statement on Proficiencies for the APRN Gerontological Specialist, Proficiency Statement 7.
Chief complaint, history of present illness and review of systems
Introduction and background The APRN Gerontological Specialist (APRN-GS) in the care of older adults provides palliative care throughout the illness trajectory when the shared goals of care are to maintain optimal function, relieve symptoms, reduce burdensome interventions, and promote quality of life.2e4 The APRN-GS discusses advanced care directives, provides information on palliative and hospice care services, identifies when persons are eligible for hospice services, guides exploratory conversation regarding the pros and cons of lifesustaining treatments, and reviews and updates plans of care based on changes in condition or situation. The APRN-GS advocates for appropriate palliative and end-of-life care across care settings
E-mail address: [email protected]. 0197-4572/$ e see front matter http://dx.doi.org/10.1016/j.gerinurse.2016.12.007
M. D. is an 86-year-old female who has moderate to advanced Alzheimer’s Type Dementia and is a resident of an assisted living facility. She is seen by the nurse practitioner, an APRN-GS, for report of a stage II ulcer of the left hip. The Assisted Living Facility (ALF) nurse (an LPN) caring for Mrs. D, and Mrs. D’s daughter (and Durable Power of Attorney) are present at the visit. Since Mrs. D’s ability to communicate is impaired, the nurse practitioner, an APRN-GS, interviews the nurse and daughter regarding Mrs. D’s symptoms and status. History of Present Illness: Mrs. D’s daughter reports that she received a phone call from the ALF nurse who notified her that her mother was noticed to have a “bedsore” on her left hip yesterday and that the staff were going to notify the APRNGS and schedule a visit. She states that upon being told that her mother had a bedsore, she immediately came to the ALF, examined the wound and asked the nurse to place a protective dressing on the area until further treatment was prescribed. The ALF nurse reports that the wound was first noticed one day ago, by the nursing assistant when she was showering Mrs. D. Mrs. D’s daughter states that this is the first bedsore her mother has had and that she is concerned that her mother is declining. The APRN-GS asks Mrs. D’s
GAPNA Section / Geriatric Nursing 38 (2017) 80e82
daughter if there are other symptoms or changes in condition that are concerning. Mrs. D’s daughter states that she has noticed 3 main changes in her mother: 1) “she can speak . but the words don’t make any sense;” 2) “she cannot help dress herself, transfer into the bed or sit upright in the wheelchair unless she is propped up with pillows;” and 3) “some days she eats and drinks very little . it’s more of a struggle to get her to eat.” The APRN-GS asks Mrs. D’s nurse if there are any other concerns or changes in condition. Mrs. D’s nurse states that she agrees with the concerns listed by the daughter and states she is also concerned about Mrs. D’s poor appetite, frequent medication refusal, inability to transfer or reposition herself and has observed frequent episodes of crying. She reports that all of the medications are being crushed for administration and that Mrs. D often “spits her meds out . and closes her eyes and gets upset when we try to give her the eye drops.” The nurse also reports that Mrs. D is receiving a pureed diet “because she sometimes seems to have trouble swallowing.” The APRN-GS reviews Mrs. D’s medical record and interviews the daughter and ALF nurse, collecting the following information: Past Medical history: Alzheimer’s Type Dementia (age 76), Essential Hypertension (age 74), Hypothyroidism (age 74), Osteoarthritis bilateral knees and feet, Glaucoma, Depression (age 74), Chronic Colonic Constipation, Appendectomy (age 24), Cataract surgery right eye (age 83). Allergies: no known drug or food allergies. Medications: Losartan/HCTZ 100/12.5 mg daily; Metoprolol Tartrate 25 mg twice daily; L-Thyroxine 25 mcg daily; Venlafaxine HCL ER 150 mg daily; Lorazepam 0.5 mg twice daily as needed; Donepezil HCL 10 mg daily at bedtime; Memantine 10 mg twice daily; Latanoprost Opthalmic Solution 0.005% one drop in each eye every evening; Miralax one capful daily. Review of Systems (per Mrs. D’s daughter and nurse) HEENT: report of frequent runny nose with clear nasal discharge; no apparent sore throat. Has glasses but does not wear them. No hearing aids and hearing is “good.” Heart and Chest: occasional cough when eating or drinking, no shortness of breath or chest pain. Abdomen: no nausea or vomiting, no diarrhea or constipation, no apparent abdominal pain; report of incontinence of soft brown stool, usually has bowel movement twice daily. Genitourinary: no rashes, incontinent of urine. Musculoskeletal: report of generalized muscle weakness; stiffness of knees; no lower extremity edema. Neurological: answers to her name; unable to recognize objects. Skin: reported to have “bedsore” of left hip; no apparent itching or painful areas. Family and social history Mrs. D is a widow of 14 years, and the youngest of 3 siblings. She has no living siblings, her brother died from bleeding esophageal varices (age 50); sister died of dementia (age 83); father died of “old age” (age 93); mother died from complications of hip fracture (age 87). She has two adult children (one son and one daughter), three grandchildren and four great-grandchildren. Her daughter is her durable power of attorney (medical and financial). She has been a resident of the ALF for the past four years due to a decline in selfcare abilities related to her dementia. Mrs. D’s advanced directives are as follows: do not resuscitate, no hospitalization, no tube feeding, comfort measures only and antibiotics if needed. Mrs. D’s daughter reports that her mother has not been ambulatory in over two years, that over the past 3 months she has noticed a sharp decline in Mrs. D’s functioning, and that Mrs. D seems to forget to chew when eating, is very slow in her movements, falls asleep during conversations, and has difficulty completing simple tasks, such as brushing her teeth. The nurse reports that Mrs. D is cooperative with care but sometimes becomes anxious, confused and tearful when receiving care or when she is in the dining room. Mrs. D’s daughter states that her mother has never smoked nor drank
81
alcohol. She reports that Mrs. D retired from General Motors where she worked as an accounting clerk for over 30 years. She describes her mother as a devout Baptist, who prayed often and read her Bible. Physical examination Mrs. D is a frail appearing, confused elderly white female who is awake and smiles when she is spoken to. Her vital signs were: Blood pressure 100/60 mmHg (sitting); Pulse: regular e 60 bpm; Respirations: 18/min; Temperature: 97.6 F; Pulse Oximetry: 94%; Weight: 101 pounds (19-pound weight loss in past 6 months); Height: 66 inches. BMI: 16.3. HEENT: Normocephalic, atraumatic. Pupils 2 mm round and reactive to light; anicteric sclera, yellow mucoid crust matted in eyelashes. Ears e tympanic membranes visible, small amount of yellow cerumen in external canal of right ear. Nasal mucosa pink, some clear nasal drainage present in nares. Oral mucosa moist, no oral lesions; Oropharnyx clear, no exudates or erythema. Neck: trachea midline; no thyroid enlargement or nodules; no cervical lymphadenopathy. Chest: equal bilateral chest expansion; lungs clear to auscultation. Heart and Peripheral Vascular: normal S1, S2, regular rate and rhythm, no murmurs; No peripheral edema; dorsalis pedis and pedal pulses þ2. Abdomen: scaphoid; non-tender; no organomegaly; no hernias; bowel sounds present in all four quadrants. Genitourinary/Rectal: no rashes; incontinent of urine; soft brown stool in the rectal vault; rectal hemorrhoids present. Musculoskeletal: generalized muscle wasting; degenerative joint changes of bilateral knees; knees positive for crepitation with range of motion; restricted extension of left knee due to flexion contracture. Neurological: Awake, confused to time, place and situation, oriented to name only. Equal weak hand grips; sensation intact; reflexes þ2 bilateral biceps, triceps and Achilles. Skin: stage II dermal ulcer of left trochanter, pink granulation tissue present at wound bed, no slough or discharge. Coccyx and right trochanter reddened non-blanchable skin. No other lesions of skin. Fingernails e thickened yellowed nails of 4th and 5th digits both hands; thick yellow toenails both feet. Assessment and discussion The APRN Gerontological Specialist recognizes the complexity of Mrs. D’s condition and the importance of using validated assessment tools to aid in assessment and the communication of findings to Mrs. D’s daughter in order to facilitate compassionate discussion of Mrs. D’s prognosis and plan of care. Using the Palliative Performance Scale (PPS) and the Functional Assessment Staging Test (FAST),6 the APRNGS notes that Mrs. D scores <40% on the PPS (i.e., mainly in bed, total care, reduced intake, confusion), and stage 7d on the FAST Scale (i.e., limitations include those listed in stages 1e6 plus, <6 intelligible words in a given day, cannot walk, cannot sit-up without assistance). Accordingly, the APRN-GS asks if Mrs. D’s daughter would like to discuss examination findings and the plan of care in the family conference room. Mrs. D’s daughter responds that she would be very appreciative of a private environment to discuss Mrs. D’s condition and plan of care. The APRN-GS begins the discussion stating, “It’s a pleasure to take care of your mother, I can see how attentive you’ve been, and I understand how very difficult it is to see your mother declining from the effects of Alzheimer’s Dementia. I’d like to review your mother’s examination findings and then, your plan of care preferences for your mother.” The APRN-GS reviews the findings of the examination with Mrs. D’s daughter, these include: 1) Stage II dermal ulcer left hip without signs of infection; Stage I pressure sores of coccyx and right hip; 2) Advanced Dementia e Alzheimer’s Type with progressive decline in functional status as evidenced by daughter and nurse’s observations, decreased oral intake, a PPS of
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<40% and FAST score of 7d; 3) Nineteen pound unintentional weight loss in the past 6 months due to poor oral intake, possibly an indication of Adult Failure to Thrive and/or impaired swallow; 4) History of Hypertension- normotensive/borderline hypotension, possibly volume depleted secondary to diuretic and combination antihypertensive medications; 5) Depression e with occasional tearful episodes; 6) Hypothyroidism e unknown TSH; 6) Chronic Colonic Constipation e resolved; 7) Bilateral Knee Osteoarthritis with flexion contracture left knee e question of adequate pain management; 8) Glaucoma/Eye discharge e eye pressure unknown, infrequently receives glaucoma eye drops; crusted discharge on eyelids, likely due to inadequate eye hygiene 9) Onychomycosis e no current treatment and 10) Missed medications due to frequent refusal of medications.
been covered in their discussion and states, “I realize this is a difficult conversation and I’ve covered a lot of information today, please don’t feel rushed to make any decisions today. I encourage you to discuss this information with your family, and call me with any questions, concerns and your decisions.” Mrs. D’s daughter states that she understands the suggested plan of care and agrees. She is able to repeat the plan of care back to the APRN-GS, validating her understanding. She also requests a referral for Hospice evaluation and asks how soon the evaluation will occur. The APRNGS summarizes the plan of care and informs Mrs. D’s daughter that the hospice team will call to set-up an appointment, and that this is usually able to take place within 1e2 days. Summary
Plan of care The APRN-GS explains that since Mrs. D’s condition has changed, it is essential to review her Advanced Care Directives, type of care desired, and the preferred setting for care, in order to provide high-quality care consistent with patient and family care preferences. Mrs. D’s daughter states that it is her mother’s wishes to avoid unnecessary testing, hospitalization, and absolutely no tube feeding or CPR “under any circumstances.” She states, “My brother and I want to honor mother’s wishes and just want to keep mother as comfortable as possible during the time she has left.” The APRN-GS reviews the stages of dementia and explains that Mrs. D is in the advanced stage of dementia, is at risk for dehydration, infections, and additional skin breakdown due to immobility, weight loss and poor nutrition. The APRN-GS offers several comfort interventions that could be implemented immediately and asks if she would like information on palliative and hospice care services or a referral for hospice evaluation. The APRN-GS suggests the following interventions: 1) wound care to the left hip with daily wound cleansing, dermagram ointment to the wound and a protective dressing, turning and repositioning every 2 h, pressure relieving air mattress; 2) speech and swallow consult; 3) one-on-one feeding7; dietary supplements three times daily as tolerated; 4) eye hygiene with baby shampoo three times daily; 5) Ibuprofen 400 mg three times daily; 6) Monitor blood pressure daily for hypotension; 7) Consider lab draw for CBC, Comprehensive Metabolic panel, and TSH to detect treatable infection or metabolic derangement; 8) Adjust medications: discontinue Venlafaxine HCL ER 150 mg (should not be crushed) change to Venlafaxine HCL 150 mg daily (immediate release); discontinue Losartan/HCTZ 100/12.5 mg daily (to avoid exacerbation of dehydration/hypotension); discontinue Miralax one capful daily (due to poor oral intake); Consider discontinuance of Donepezil HCL 10 mg daily at bedtime (due to poor intake, missed doses and change to comfort plan of care), Memantine 10 mg twice daily (due to poor intake, missed doses and change to comfort plan of care) and Latanoprost Opthalmic Solution eye drops (due to agitation/ irritation with treatment); Continue e Metoprolol Tartrate 25 mg twice daily, L-Thyroxine 25 mcg daily, and Lorazepam 0.5 mg twice daily as needed for anxiety/restlessness. The APRN-GS asks Mrs. D’s daughter if she has any questions or concerns that perhaps have not
This case demonstrates the importance of prompt recognition of a patient presenting with life-limiting illness and a declining condition. In this case the APRN-GS demonstrates the timely implementation of appropriate treatments within the care preferences of the patient and family in order to help alleviate suffering and provide comfort to the patient suffering with advanced dementia. The APRNGS demonstrated use of multidimensional assessment, employing validated assessment tools (i.e., PPS and FAST) that aided in prognostication and helped to guide end-of-life care conversation. Interventions to support quality of life at end-of-life, including wound care, adequate pain management, reducing burdensome treatments, and hospice referral were provided. The APRN-GS employed guideline consistent and individualized care in clarifying advance directives, establishing a therapeutic relationship, engaging in shared decision-making, affirming Mrs. D’s daughter’s emotions, and validating and addressing her concerns in care conference.8 This case reveals how the APRN-GS is uniquely positioned to provide a primary level of palliative care when needed, and how the APRN-GS can be a catalyst in activating timely secondary and tertiary level palliative and hospice care services when indicated.
References 1. Gerontological Advanced Practice Nurses Association (GAPNA). GAPNA Consensus Statement on Proficiencies for the APRN Gerontological Specialist. Pitman, NJ: Gerontological Advanced Practice Nurses Association (GAPNA); 2015. 2. Hinds P, Meghani S. The institute of medicine’s 2014 Committee on approaching death report: recommendations and Implications for Nursing. J Hospice Palliat Nurs. 2014;16(8):543e548. 3. Jerant A, Azari R, Nesbitt T, Meyers F. The TLC model of palliative care in the elderly: preliminary application in the assisted living setting. Ann Fam Med. 2004;2(1):54e60. 4. National Consensus Project on Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 3rd ed. Pittsburgh: National Consensus Project for Quality Palliative Care; 2013. ISBN 1-934654-3. 5. Henderson ML. Gerontological advance practice nurses: as end-of life care facilitators. Geriatr Nurs. 2004;25(4):233e237. 6. Reisberg B, Ferris SH, de Leon MJ, Crook T. The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatry. 1982;139:1136e 1139, www.fhca.org/members/qi/clinadmin/global.pdf. 7. Bachelor-Murphy, M. Handfeeding techniques for assisting persons with dementia. https://www.youtube.com/watch?v¼NYzH_B7XfjY. 8. McCusker M, Ceronsky L, Crone C, et al. Palliative Care for Adults. Institute for Clinical Systems Improvement; Updated November 2013.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
GAPNA Section
Exemplars in advanced practice gerontological nursing: A GAPNA Series e GAPNA Consensus Statement Proficiency 7 e Case 7 Deborah Dunn, EdD, MSN, GNP-BC, ACNS-BC Graduate School, Madonna University, Livonia, MI, USA
APRN Gerontological Specialist Proficiency Statement 7 The APRN Gerontological Specialist is proficient in coordination and management of timely palliative and end-of-life care congruent with the goals and values of older adults and families/ carers. The APRN Gerontological Specialist provides the full scope of care from preventive to curative to palliative and end-of-life care. Through the application of exquisite holistic and multidimensional assessment skills, the Gerontological Specialist identifies progressive life-limiting illness and works to develop plans of care congruent with the goals and values of older adults, and their family/carers to reduce distress and increase comfort.1
and works with the interprofessional team to coordinate timely palliative and end-of-life care with older adults and their families/ carers.5 The importance of accurate prognostication about life expectancy, truth-telling and early disclosure cannot be stressed enough in the discussion of appropriate care of persons with end-stage or life-limiting illness. Quality of life can be enhanced when patients and families have time to set goals, and consider what type of endof-life care they desire. Entering palliative care earlier may actually improve quality of life through reductions in hospitalization, medical interventions, intensive care services and limiting unnecessary suffering.
Overview
Case 7: Margaret Delaney
This case is presented as the seventh in a series of case illustrations developed to provide clinical examples of the application of GAPNA’s APRN Gerontological Specialist Proficiencies. This case highlights GAPNA’s Consensus Statement on Proficiencies for the APRN Gerontological Specialist, Proficiency Statement 7.
Chief complaint, history of present illness and review of systems
Introduction and background The APRN Gerontological Specialist (APRN-GS) in the care of older adults provides palliative care throughout the illness trajectory when the shared goals of care are to maintain optimal function, relieve symptoms, reduce burdensome interventions, and promote quality of life.2e4 The APRN-GS discusses advanced care directives, provides information on palliative and hospice care services, identifies when persons are eligible for hospice services, guides exploratory conversation regarding the pros and cons of lifesustaining treatments, and reviews and updates plans of care based on changes in condition or situation. The APRN-GS advocates for appropriate palliative and end-of-life care across care settings
E-mail address: [email protected]. 0197-4572/$ e see front matter http://dx.doi.org/10.1016/j.gerinurse.2016.12.007
M. D. is an 86-year-old female who has moderate to advanced Alzheimer’s Type Dementia and is a resident of an assisted living facility. She is seen by the nurse practitioner, an APRN-GS, for report of a stage II ulcer of the left hip. The Assisted Living Facility (ALF) nurse (an LPN) caring for Mrs. D, and Mrs. D’s daughter (and Durable Power of Attorney) are present at the visit. Since Mrs. D’s ability to communicate is impaired, the nurse practitioner, an APRN-GS, interviews the nurse and daughter regarding Mrs. D’s symptoms and status. History of Present Illness: Mrs. D’s daughter reports that she received a phone call from the ALF nurse who notified her that her mother was noticed to have a “bedsore” on her left hip yesterday and that the staff were going to notify the APRNGS and schedule a visit. She states that upon being told that her mother had a bedsore, she immediately came to the ALF, examined the wound and asked the nurse to place a protective dressing on the area until further treatment was prescribed. The ALF nurse reports that the wound was first noticed one day ago, by the nursing assistant when she was showering Mrs. D. Mrs. D’s daughter states that this is the first bedsore her mother has had and that she is concerned that her mother is declining. The APRN-GS asks Mrs. D’s
GAPNA Section / Geriatric Nursing 38 (2017) 80e82
daughter if there are other symptoms or changes in condition that are concerning. Mrs. D’s daughter states that she has noticed 3 main changes in her mother: 1) “she can speak . but the words don’t make any sense;” 2) “she cannot help dress herself, transfer into the bed or sit upright in the wheelchair unless she is propped up with pillows;” and 3) “some days she eats and drinks very little . it’s more of a struggle to get her to eat.” The APRN-GS asks Mrs. D’s nurse if there are any other concerns or changes in condition. Mrs. D’s nurse states that she agrees with the concerns listed by the daughter and states she is also concerned about Mrs. D’s poor appetite, frequent medication refusal, inability to transfer or reposition herself and has observed frequent episodes of crying. She reports that all of the medications are being crushed for administration and that Mrs. D often “spits her meds out . and closes her eyes and gets upset when we try to give her the eye drops.” The nurse also reports that Mrs. D is receiving a pureed diet “because she sometimes seems to have trouble swallowing.” The APRN-GS reviews Mrs. D’s medical record and interviews the daughter and ALF nurse, collecting the following information: Past Medical history: Alzheimer’s Type Dementia (age 76), Essential Hypertension (age 74), Hypothyroidism (age 74), Osteoarthritis bilateral knees and feet, Glaucoma, Depression (age 74), Chronic Colonic Constipation, Appendectomy (age 24), Cataract surgery right eye (age 83). Allergies: no known drug or food allergies. Medications: Losartan/HCTZ 100/12.5 mg daily; Metoprolol Tartrate 25 mg twice daily; L-Thyroxine 25 mcg daily; Venlafaxine HCL ER 150 mg daily; Lorazepam 0.5 mg twice daily as needed; Donepezil HCL 10 mg daily at bedtime; Memantine 10 mg twice daily; Latanoprost Opthalmic Solution 0.005% one drop in each eye every evening; Miralax one capful daily. Review of Systems (per Mrs. D’s daughter and nurse) HEENT: report of frequent runny nose with clear nasal discharge; no apparent sore throat. Has glasses but does not wear them. No hearing aids and hearing is “good.” Heart and Chest: occasional cough when eating or drinking, no shortness of breath or chest pain. Abdomen: no nausea or vomiting, no diarrhea or constipation, no apparent abdominal pain; report of incontinence of soft brown stool, usually has bowel movement twice daily. Genitourinary: no rashes, incontinent of urine. Musculoskeletal: report of generalized muscle weakness; stiffness of knees; no lower extremity edema. Neurological: answers to her name; unable to recognize objects. Skin: reported to have “bedsore” of left hip; no apparent itching or painful areas. Family and social history Mrs. D is a widow of 14 years, and the youngest of 3 siblings. She has no living siblings, her brother died from bleeding esophageal varices (age 50); sister died of dementia (age 83); father died of “old age” (age 93); mother died from complications of hip fracture (age 87). She has two adult children (one son and one daughter), three grandchildren and four great-grandchildren. Her daughter is her durable power of attorney (medical and financial). She has been a resident of the ALF for the past four years due to a decline in selfcare abilities related to her dementia. Mrs. D’s advanced directives are as follows: do not resuscitate, no hospitalization, no tube feeding, comfort measures only and antibiotics if needed. Mrs. D’s daughter reports that her mother has not been ambulatory in over two years, that over the past 3 months she has noticed a sharp decline in Mrs. D’s functioning, and that Mrs. D seems to forget to chew when eating, is very slow in her movements, falls asleep during conversations, and has difficulty completing simple tasks, such as brushing her teeth. The nurse reports that Mrs. D is cooperative with care but sometimes becomes anxious, confused and tearful when receiving care or when she is in the dining room. Mrs. D’s daughter states that her mother has never smoked nor drank
81
alcohol. She reports that Mrs. D retired from General Motors where she worked as an accounting clerk for over 30 years. She describes her mother as a devout Baptist, who prayed often and read her Bible. Physical examination Mrs. D is a frail appearing, confused elderly white female who is awake and smiles when she is spoken to. Her vital signs were: Blood pressure 100/60 mmHg (sitting); Pulse: regular e 60 bpm; Respirations: 18/min; Temperature: 97.6 F; Pulse Oximetry: 94%; Weight: 101 pounds (19-pound weight loss in past 6 months); Height: 66 inches. BMI: 16.3. HEENT: Normocephalic, atraumatic. Pupils 2 mm round and reactive to light; anicteric sclera, yellow mucoid crust matted in eyelashes. Ears e tympanic membranes visible, small amount of yellow cerumen in external canal of right ear. Nasal mucosa pink, some clear nasal drainage present in nares. Oral mucosa moist, no oral lesions; Oropharnyx clear, no exudates or erythema. Neck: trachea midline; no thyroid enlargement or nodules; no cervical lymphadenopathy. Chest: equal bilateral chest expansion; lungs clear to auscultation. Heart and Peripheral Vascular: normal S1, S2, regular rate and rhythm, no murmurs; No peripheral edema; dorsalis pedis and pedal pulses þ2. Abdomen: scaphoid; non-tender; no organomegaly; no hernias; bowel sounds present in all four quadrants. Genitourinary/Rectal: no rashes; incontinent of urine; soft brown stool in the rectal vault; rectal hemorrhoids present. Musculoskeletal: generalized muscle wasting; degenerative joint changes of bilateral knees; knees positive for crepitation with range of motion; restricted extension of left knee due to flexion contracture. Neurological: Awake, confused to time, place and situation, oriented to name only. Equal weak hand grips; sensation intact; reflexes þ2 bilateral biceps, triceps and Achilles. Skin: stage II dermal ulcer of left trochanter, pink granulation tissue present at wound bed, no slough or discharge. Coccyx and right trochanter reddened non-blanchable skin. No other lesions of skin. Fingernails e thickened yellowed nails of 4th and 5th digits both hands; thick yellow toenails both feet. Assessment and discussion The APRN Gerontological Specialist recognizes the complexity of Mrs. D’s condition and the importance of using validated assessment tools to aid in assessment and the communication of findings to Mrs. D’s daughter in order to facilitate compassionate discussion of Mrs. D’s prognosis and plan of care. Using the Palliative Performance Scale (PPS) and the Functional Assessment Staging Test (FAST),6 the APRNGS notes that Mrs. D scores <40% on the PPS (i.e., mainly in bed, total care, reduced intake, confusion), and stage 7d on the FAST Scale (i.e., limitations include those listed in stages 1e6 plus, <6 intelligible words in a given day, cannot walk, cannot sit-up without assistance). Accordingly, the APRN-GS asks if Mrs. D’s daughter would like to discuss examination findings and the plan of care in the family conference room. Mrs. D’s daughter responds that she would be very appreciative of a private environment to discuss Mrs. D’s condition and plan of care. The APRN-GS begins the discussion stating, “It’s a pleasure to take care of your mother, I can see how attentive you’ve been, and I understand how very difficult it is to see your mother declining from the effects of Alzheimer’s Dementia. I’d like to review your mother’s examination findings and then, your plan of care preferences for your mother.” The APRN-GS reviews the findings of the examination with Mrs. D’s daughter, these include: 1) Stage II dermal ulcer left hip without signs of infection; Stage I pressure sores of coccyx and right hip; 2) Advanced Dementia e Alzheimer’s Type with progressive decline in functional status as evidenced by daughter and nurse’s observations, decreased oral intake, a PPS of
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GAPNA Section / Geriatric Nursing 38 (2017) 80e82
<40% and FAST score of 7d; 3) Nineteen pound unintentional weight loss in the past 6 months due to poor oral intake, possibly an indication of Adult Failure to Thrive and/or impaired swallow; 4) History of Hypertension- normotensive/borderline hypotension, possibly volume depleted secondary to diuretic and combination antihypertensive medications; 5) Depression e with occasional tearful episodes; 6) Hypothyroidism e unknown TSH; 6) Chronic Colonic Constipation e resolved; 7) Bilateral Knee Osteoarthritis with flexion contracture left knee e question of adequate pain management; 8) Glaucoma/Eye discharge e eye pressure unknown, infrequently receives glaucoma eye drops; crusted discharge on eyelids, likely due to inadequate eye hygiene 9) Onychomycosis e no current treatment and 10) Missed medications due to frequent refusal of medications.
been covered in their discussion and states, “I realize this is a difficult conversation and I’ve covered a lot of information today, please don’t feel rushed to make any decisions today. I encourage you to discuss this information with your family, and call me with any questions, concerns and your decisions.” Mrs. D’s daughter states that she understands the suggested plan of care and agrees. She is able to repeat the plan of care back to the APRN-GS, validating her understanding. She also requests a referral for Hospice evaluation and asks how soon the evaluation will occur. The APRNGS summarizes the plan of care and informs Mrs. D’s daughter that the hospice team will call to set-up an appointment, and that this is usually able to take place within 1e2 days. Summary
Plan of care The APRN-GS explains that since Mrs. D’s condition has changed, it is essential to review her Advanced Care Directives, type of care desired, and the preferred setting for care, in order to provide high-quality care consistent with patient and family care preferences. Mrs. D’s daughter states that it is her mother’s wishes to avoid unnecessary testing, hospitalization, and absolutely no tube feeding or CPR “under any circumstances.” She states, “My brother and I want to honor mother’s wishes and just want to keep mother as comfortable as possible during the time she has left.” The APRN-GS reviews the stages of dementia and explains that Mrs. D is in the advanced stage of dementia, is at risk for dehydration, infections, and additional skin breakdown due to immobility, weight loss and poor nutrition. The APRN-GS offers several comfort interventions that could be implemented immediately and asks if she would like information on palliative and hospice care services or a referral for hospice evaluation. The APRN-GS suggests the following interventions: 1) wound care to the left hip with daily wound cleansing, dermagram ointment to the wound and a protective dressing, turning and repositioning every 2 h, pressure relieving air mattress; 2) speech and swallow consult; 3) one-on-one feeding7; dietary supplements three times daily as tolerated; 4) eye hygiene with baby shampoo three times daily; 5) Ibuprofen 400 mg three times daily; 6) Monitor blood pressure daily for hypotension; 7) Consider lab draw for CBC, Comprehensive Metabolic panel, and TSH to detect treatable infection or metabolic derangement; 8) Adjust medications: discontinue Venlafaxine HCL ER 150 mg (should not be crushed) change to Venlafaxine HCL 150 mg daily (immediate release); discontinue Losartan/HCTZ 100/12.5 mg daily (to avoid exacerbation of dehydration/hypotension); discontinue Miralax one capful daily (due to poor oral intake); Consider discontinuance of Donepezil HCL 10 mg daily at bedtime (due to poor intake, missed doses and change to comfort plan of care), Memantine 10 mg twice daily (due to poor intake, missed doses and change to comfort plan of care) and Latanoprost Opthalmic Solution eye drops (due to agitation/ irritation with treatment); Continue e Metoprolol Tartrate 25 mg twice daily, L-Thyroxine 25 mcg daily, and Lorazepam 0.5 mg twice daily as needed for anxiety/restlessness. The APRN-GS asks Mrs. D’s daughter if she has any questions or concerns that perhaps have not
This case demonstrates the importance of prompt recognition of a patient presenting with life-limiting illness and a declining condition. In this case the APRN-GS demonstrates the timely implementation of appropriate treatments within the care preferences of the patient and family in order to help alleviate suffering and provide comfort to the patient suffering with advanced dementia. The APRNGS demonstrated use of multidimensional assessment, employing validated assessment tools (i.e., PPS and FAST) that aided in prognostication and helped to guide end-of-life care conversation. Interventions to support quality of life at end-of-life, including wound care, adequate pain management, reducing burdensome treatments, and hospice referral were provided. The APRN-GS employed guideline consistent and individualized care in clarifying advance directives, establishing a therapeutic relationship, engaging in shared decision-making, affirming Mrs. D’s daughter’s emotions, and validating and addressing her concerns in care conference.8 This case reveals how the APRN-GS is uniquely positioned to provide a primary level of palliative care when needed, and how the APRN-GS can be a catalyst in activating timely secondary and tertiary level palliative and hospice care services when indicated.
References 1. Gerontological Advanced Practice Nurses Association (GAPNA). GAPNA Consensus Statement on Proficiencies for the APRN Gerontological Specialist. Pitman, NJ: Gerontological Advanced Practice Nurses Association (GAPNA); 2015. 2. Hinds P, Meghani S. The institute of medicine’s 2014 Committee on approaching death report: recommendations and Implications for Nursing. J Hospice Palliat Nurs. 2014;16(8):543e548. 3. Jerant A, Azari R, Nesbitt T, Meyers F. The TLC model of palliative care in the elderly: preliminary application in the assisted living setting. Ann Fam Med. 2004;2(1):54e60. 4. National Consensus Project on Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 3rd ed. Pittsburgh: National Consensus Project for Quality Palliative Care; 2013. ISBN 1-934654-3. 5. Henderson ML. Gerontological advance practice nurses: as end-of life care facilitators. Geriatr Nurs. 2004;25(4):233e237. 6. Reisberg B, Ferris SH, de Leon MJ, Crook T. The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatry. 1982;139:1136e 1139, www.fhca.org/members/qi/clinadmin/global.pdf. 7. Bachelor-Murphy, M. Handfeeding techniques for assisting persons with dementia. https://www.youtube.com/watch?v¼NYzH_B7XfjY. 8. McCusker M, Ceronsky L, Crone C, et al. Palliative Care for Adults. Institute for Clinical Systems Improvement; Updated November 2013.