- Email: [email protected]
Nurses in adult day care centers
Nurses IN ADULT DAY Care CENTERS Andrea Jennings-Sanders, DrPH, RN
Adult
day care services are community-based group programs designed to support adults’ personal independence by promoting their social, physical, and emotional wellbeing through an individual plan of care. Nurses are in a prime position to care for this population because they deliver holistic care and promote health. Scant literature is available that addresses how nurses provide care for this population. The purpose of this article is to describe how nurses can care for the adult day care population and to present an illustrative case study that demonstrates how nurses can positively affect the health of older adult day care clients. (Geriatr Nurs 2004;25:227-32)
July/August 2004
227
T
he population of older Americans is growing, with the Ritchie7 conducted a qualitative study to explore older number of Americans older than 85 years increasing adults, caregivers, and nurse perceptions regarding adult faster than any other group.1 Seeking cost-effective day care. Older adults suggested social, physical, emotionways to help keep this population in their communial, functional, and environmental considerations as a platties and out of institutions is essential. Utilizing adult form for implementing adult day care programs. The nurse day care centers is a venue that allows older adults to participants suggested that the adult day programs include remain in their community and avoid institutionalization. A client and family health education programs. Caregivers recent study by Partners in Caregiving found that there is a suggested that adult day care programs have a respite progrowing need for more adult day care centers, citing that gram to alleviate caregiver stress. All participates agreed adult day care systems have not kept up with the aging popthat adult day care services were essential to the health and ulation growth.2 Adult day care services are communitywell-being of older adults and their caregivers. based group programs designed to support adults’ personal Travis8 analyzed the development of adult day care independence by promoting their social, physical, and emonursing services and described the need for the nursing tional well-being through an individual plan of care.3 This profession to be more proactive in delineating skills and plan of care encompasses services such as transportation, knowledge requirements for nurses practicing in adult day social services, meals, nursing care, personal care, counselcare centers. The author noted that the little information ing, therapeutic activities, and rehabilitation therapies. Adult known about the provision of nursing services in adult day day care is reimbursable through Medicaid, and a sliding fee care came from various national surveys such as the scale is available for those who do not qualify for Medicaid National Adult Day Care Survey. Travis et al9 also exambenefits. Other funding sources include private pay, foundained the characteristics of participants in and providers of tions, and long-term care insurance. adult day care services in centers throughout the state of There are two primary models of adult day care: the Oklahoma. Their findings revealed that the majority of medical model and the social model. The medical model participants had limited communication deficits and low includes services offered by an array rates of incontinence, but notable cogof professionals who administer care nitive impairment. Discharge data from to adult day care clients; these may adult day care programs suggested that Adult day CARE is REIMBURSABLE include on-site registered nurses, participants required more intense medthrough MEDICAID, and a speech therapists, occupational therical or supportive care (or both). apists, physical therapists, social Dabelko10 compared adult day sersliding FEE scale is AVAILABLE workers, and registered dieticians. vices and home care users on the indiThe social model stresses social cators of personal characteristics, physfor those who DO NOT QUALIFY activities, maintenance of client ical health, mental health, and social for MEDICAID benefits. functioning, nutrition, and recrenetwork contacts. Results indicated that ation for adult day care clients. adult day care users were younger, had Some adult day care centers use the greater cognitive impairment, had more medical model, and others use the social model or a comsocial contacts, and needed more supervisory assistance bination of both models.4 with activities of daily living. The authors suggested that strategies encompassing integrated care models addressL I T E R AT U R E R E V I E W ing physical, mental, and social needs of older adults in A study of adult day services was conducted nationboth the home health care setting and adult day care setwide.5 The study found that the average age of the adult ting are needed. day care consumer was 72 years, and over one-half of all Raehl11 found that seniors’ ability to take oral prescripof the participants had some cognitive impairment. Fiftytion medications safely correlated with age, gender, socioefive percent of the participants lived with an adult child or conomic status, education, cognitive impairment, depresspouse. The National Council on Aging6 conducted a sion, and drug self-management in 3 retirement communistudy examining the need of health and supportive serties and 1 adult day care center. Results indicated that older vices programs in community-based programs such as adults’ ability to take oral prescription medications safely adult day care centers. The results of this study indicated was affected by cognitive function and socioeconomic stathat there is a great need for more programs in adult day tus. A Med Take test was administered to all clients to evalcare centers that target social support, caregiving, physical uate dosage, indication, food or water congestion, and regidisability, and chronic disease self-management. men. Jennings-Sanders12 examined medication knowledge Based on the findings from these studies, care that and behavior of older African American adult day care encompasses social support and management of chronic clients. Findings from this study suggested that there were diseases is needed. At present, there are some adult day care many factors affecting medication regimen compliance centers that utilize nurses, but little has been published on such as caregiver noncompliance, lack of communication the nurse’s role in providing nursing care to this population. with physicians, physical limitations, high costs of medica-
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tions, and utilization of home remedies. The author recomchallenging. These behaviors may include confusion, mended that nurses educate clients about their medications, aggression, hoarding, sundown syndrome, and wandering. be a client advocate, and provide case management to The Dementia Assessment Tool16 measures loss of intelincrease adherence in medication regimens. Nurses could lectual functioning and memory over time. After utilizing do continuous medication assessments and serve as a liaithe tool and consulting with a physician, the nurse will son between the pharmacist and physician and the client to know what type of education and support is needed for the decrease medication adherence problems. client and their caregiver. Nelson13 conducted an ethnographic study to establish Medication Assessment Tool a knowledge base for a practice model of culturally congruent adult day care. The study examined kinship, social, Adult day care clients suffer from many chronic disspiritual, and cultural factors. The data revealed many simeases and therefore use more medications than any other ilarities in the kinship, social, group. The How to Assess the “At spiritual, and cultural factors Risk” Geriatric Client Tool17 asks DATA revealed many similarities in influencing the perceptions of the client to 1) give a complete caring among adult day care cenmedication history; 2) make a list the KINSHIP, SOCIAL, SPIRITUAL, and ter clients, family members, staff of each medication, noting its members, and volunteers. The name, strength, and directions; 3) CULTURAL factors INFLUENCING the analysis also revealed that there identify all physicians prescribing PERCEPTIONS of CARING among adult was substantial congruence in the the medication; 4) question care expressions, patterns, and clients about their self-medicaday care center CLIENTS, FAMILY practices in the centers and tion practices; and 5) describe clients’ homes. The findings from any limitations that may impair members, STAFF members, and this study sheds additional light safe, self-administration of mediVOLUNTEERS. regarding a practice model of culcations. The information from turally congruent adult day care this tool allows the nurse to idenfor nurses working in adult day care centers. tify any problems affecting medication adherence. P R O V I D I N G C A R E T O T H E A D U LT D AY C A R E P O P U L AT I O N Assessment Strengths and weaknesses should be identified for each adult day care client. Each client has their own unique set of circumstances. The identification of strengths and weaknesses can be done using assessment tools readily available in the literature. The following examples of assessment tools may be useful for nurses developing effective plans of care for adult day care clients.
Activities of Daily Living and Instrumental Activities of Daily Living Assessment Tools The assessment of the client’s ability to perform activities of daily living provides the nurse with data to indicate the client’s self care ability. Katz14 developed the Index of Independence in Basic Activities of Daily Living, which is based on an evaluation of the functional independence or dependence of clients in feeding, bathing, dressing, toileting, transferring, and continence. The Instrumental Activities of Daily Living Assessment, developed by Lawton and Brody,15 has 8 categories of a client’s level of functioning: 1) using the telephone, 2) shopping, 3) food preparation, 4) housekeeping, 5) laundry, 6) using a mode of transportation, 7) responsibility for own medications, and 8) handling finances.
Dementia Assessment Tool Dementia can result in behaviors that caregivers find July/August 2004
Multicultural Assessment Tool Nurses need to be aware that older adult day care clients are influenced by their culture, and those cultural differences can adversely affect the relationship between the client and health care provider. The Multicultural Nursing Assessment Tool18 explores various factors (i.e., cultural, psychologic, sociologic, biologic, and physiologic). This instrument helps the nurse understand the client’s values, attitudes, and beliefs about causes of health and illness. For example, older African Americans may believe in folk medicine or home remedies and may prefer to use these methods rather than prescribed medications.
Social Network Assessment Nurses should include a social network assessment as a regular part of their client health assessment. Those adult day care clients with little or limited social networks may be at risk in adhering to their health care regimen. The Lubben Social Network Scale19 explores family networks, social (friends) networks, confidant relationships, helping others, and living arrangements.
Environmental Assessment It is important to conduct an environmental assessment at the client’s home. Older adults are often injured in their homes, and injuries such as falls may lead to additional health problems or worsen existing conditions. Many of these injuries result from hazards that are easily overlooked and avoidable. Nurses should use environmental 229
checklists to detect hazards in the homes of adult day care clients. The Environmental Assessment for the Elderly Tool20 addresses physical hazards in and outside the home and assesses any signs of neglect in the home. An in-home assessment is critical to a comprehensive plan.
Nutritional Assessment Nutritional status has a major impact on a person’s health. The Nutritional Self-Assessment Tool21 is geared toward individuals older than 65 years. It is based on key factors that may represent undernutrition and malnutrition. This tool can be utilized by the adult day care client (as well as the caregiver), who can then ask the nurse for further health advice as needed.
ically discussed and reevaluated with both the client and caregiver. Realistic time frames should be preestablished for each goal. If goals have not been met, new goals should be formed. Evidence of positive outcomes may include increased knowledge, increased self-care, increased satisfaction with nursing care, increased quality of life, and increased satisfaction of adult day care services. The following case study describes the multiple issues that can confront an adult day care client. Ways in which nurses can have a positive impact on the health of a client in adult day care are described.
CASE STUDY Mrs. S is a 72-year-old African American widow. According to the adult day care staff, she is alert and oriPlanning ented with no cognitive impairment. During the previous Planning involves establishing short- and long-term year, she attended an adult day care center 5 days each goals based on the information found in the needs-assessweek. The center is based on a social model in which ment phase. These goals should be mutually agreed on by social activities, socialization, and recreation are the the client and caregiver and have a designated time frame. focus. Mrs. S states that most of her friends have either It is during this time that other interdisciplinary team moved away or are deceased. She states that she enjoys the members are incorporated into the plan of care. Ideally, activities at the center and has developed a few friendinterdisciplinary team members may include a physician, ships. Mrs. S states she has been depressed lately, howeva nurse, and personnel from the adult day care center—for er, because of the recent death of her husband. She has example, adult day care aide, recrearthritis, diabetes, and hypertenational aide, and social worker—as sion and takes multiple medicaEvidence of POSITIVE OUTCOMES well as a family member, caregiver, tions for these conditions; she physical therapist, occupational states that she is taking 3 medicamay include increased KNOWLEDGE, therapist, speech therapist, recretions for her hypertension. Mrs. S. increased SELF-CARE, increased further states that she becomes ational therapist, podiatrist, dentist, dizzy when she takes all 3 of her and pharmacist. SATISFACTION with nursing care, hypertension medications. She Implementation was recently diagnosed with diaincreased QUALITY OF LIFE,and betes and states that she does not When implementing the plan of increased SATISFACTION of adult day know much about the disease. care for the adult day care client, Mrs. S finds it is somewhat diffithe nurse assumes various roles, CARE SERVICES. cult to perform all of her activities including that of clinician, health of daily living. She needs assiseducator, and case manager. As tance with instrumental activities of daily living. In terms clinician, the nurse may perform physical exams and conof physical limitation, she has limited use of two of her duct health screenings (e.g., cholesterol, blood pressure, fingers on her dominant hand because of arthritis. She also and blood glucose). The nurse as a health educator has the suffers from arthritis in her right foot, which causes a responsibility to educate the client and the caregiver about slight limp. She uses a cane to keep her balance. Mrs. S the client’s condition(s). Providing knowledge about availstates that her daughter provides emotional support and able resources in the community is also important for the handles her finances, but at times the daughter spends adult day care client and their caregiver. As case manager, money for “other things,” leaving Mrs. S unable to afford the nurse coordinates delivery of care, provides referrals, all of her medications. She uses home remedies for her and serves as an advocate for the adult day care client. The arthritis. Mrs. S lives alone in a large house and is on a nurse may need to coordinate care if the client is utilizing fixed income. Her daughter visits on a regular basis. She multiple health care services. In terms of providing referhas two other children who live across town but has limitrals, a client may have trouble chewing food due to malfunctioning dentures. In this instance, the nurse would ed contact with them. Mrs. S is overweight and buys most refer this client to a dentist. of her food from a small, nearby grocery store where salty, fatty, and sweet foods are sold. It is not easy to get transEvaluation portation to go another store. A registered nurse works 1 day a week at Mrs. S’s adult Evaluation is an ongoing assessment of the client’s day care center to assess the problems that clients have in short- and long-term goals. These goals should be period-
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managing their chronic conditions. In the assessment home remedies) is key. Providing information about phase, strengths and weaknesses for this particular client how to manage Mrs. S’s chronic conditions—diabetes, are delineated. arthritis, and hypertension—is also needed. A special Strengths: The client is alert and oriented without any emphasis should be placed on diabetes because the cognitive impairment. She attends adult day care 5 days a client is newly diagnosed. The client should be educatweek, and the center she attends seems appropriate ed about nutritious foods associated with effectively because it focuses on socialization. She has developed a managing her diabetes and hypertension. Educational few friendships at the center. Her daughter provides emointerventions can take place on an individual basis or tional support to her and visits on a regular basis. A registhrough focus groups. tered nurse is available on a regular basis to clients at the As case manager, the nurse will be a client advocate day care center. and provide referrals. The nurse acts as a client advocate Weaknesses: The client is depressed because of the when she speaks to the physician concerning the 3 medirecent death of her spouse. She has 3 chronic conditions, cations the client takes to control her hypertension and the takes multiple medications for each, has a knowledge deficit dizziness that she experiences. In addition, a physical about her diabetes, and needs assistance with her ADLs and therapy referral should be requested regarding the immoIADLs. She has altered mobility in her fingers and foot bility of the client’s 2 fingers and the slight limp in her because of arthritis. Her daughter handles her finances but foot. A medication organizer for the client to encourage a spends the money for “other things,” and the client is thereregular medication regimen would be useful. A list of fore unable to buy all her medications. She uses home sources where functional aides (e.g., hand grippers, dressremedies for her arthritis. Contact with her other two chiling aide sticks, or jar openers) can be purchased and infordren, who live across town, is limited. She is overweight mation on Medicare coverage for such items should be and does not have adequate transportation. offered to the client. The nurse should ask the client about Assessment tools mentioned previously were useful for the “other things” that the daughter is buying that appear the nurse to determine the extent of each of the weaknesses to be preventing the purchase of medications. Alternative identified in this case study. In the planning phase, shortways to manage the client’s finances should be discussed. and long-term goals should be set according to the weakThe daughter should be asked about her perceptions of nesses identified. An example of a what barriers exist in terms of short-term goal for the knowledge self-management of her mother’s The NURSE is ESSENTIAL because she deficit would be for the client to be chronic conditions. The nurse able to list 3 signs of hypoglycemia should ask the client if other famor he can ASSESS WEAKNESSES and when the nurse returns 1 week later. ily members are available to help An example of a long-term goal Mrs. S manage her conditions. STRENGTHS in each adult day care would be having the client attend It may be necessary for the CLIENT with the ultimate GOAL of nurse to make other referrals. monthly focus-group sessions These may include a home care regarding diabetes for at least 6 producing POSITIVE client OUTCOMES. agency to assist the client at months. The nurse, client, and family home, a pharmaceutical assismember or significant other should tance program, a drugstore delivmutually set these goals. ery program, a support group for bereavement and diaInvolvement of an interdisciplinary team would benefit betes, transportation services (e.g., to grocery stores and the client in this case study. The nurse is essential because physician appointments) offered by the adult day center, she or he can assess weaknesses and strengths in each adult and Adult Protective Services for reporting possible finanday care client with the ultimate goal of producing positive cial elder abuse. client outcomes. The personnel at the day care center (adult In the evaluation phase, short- and long-term goals day care director and recreational aides) can continue to regarding the weaknesses identified in the case study, observe the client’s behaviors and note any differences over should be evaluated and reevaluated by the nurse, client, time. The recreational aides also can consistently involve family member, and other members of the interdiscithe client in activities to increase socialization. A physical plinary team. If goals have not been met by the specified therapist may be helpful to the client in terms of prescribtime, new goals should be formed. ing specific hand and foot exercises. The physician is needed to reevaluate current medication prescriptions and monCONCLUSION itor health conditions. A social worker may be needed to Nurses working in adult day care centers can have a siginvestigate possible financial abuse. All family members nificant impact on the health of adult day care clients,8,12 should be encouraged to participate in the plan of care. who are burdened with many physical, mental, and social In terms of health education, educating the client deficits. Their roles as clinician, health educator, and case about her medications (actions, side effects, and intermanager are necessary when caring for this population. actions with other medications and with herbs and July/August 2004
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Assessment tools are essential to determine the extent of each weakness identified for the adult day care client. Nurses serving the adult day care population8,12 need to develop a clear definition of what their practice entails and describe the skills needed to work in this subspecialty.8 To define adult day care nursing further, nursing faculty will need to incorporate clinical experiences at adult day care centers for their nursing students. Future nursing research needs to focus on the positive outcomes that are a direct result of nursing care in adult day care settings. The ultimate goal is to improve the quality of life for the adult day client and maintain the highest level of independence. REFERENCES 1. Administration on Aging. A Profile of Older Americans. 2002. Available at: www.aoa.gov/prof/Statistics/profile/profiles.asp. Accessed May 2004. 2. Partners in Caregiving: The Dementia Services Program. 2003. Available at: www.rwif.org/reports/npreports/partnerse.htm. Accessed January 2003. 3. National Adult Day Care Services Association. Mission statement on adult day care. 2002. Available at www.nadsa.org. Accessed February 2003. 4. Gaugler J, Zarit S. The effectiveness of adult day care services for disabled older people. J Aging Soc Policy 2001;12(2):23-46. 5. The Robert Wood Johnson Foundation, National Study of Adult Day Care Services 2001-2002. Available at www.rwjf.org/news/special/adultday servicesSummary.jhtml. Accessed July 2004. 6. National Council Report on Aging. National Survey of Health and Supportive Services in the Aging Network. www.ncoa.org. Accessed May 2003 7. Ritchie L. Adult day care: northern perspectives. Public Health Nurs 2003;20:120-34. 8. Travis SS. Adult day services: an emerging nursing subspecialty in community based care. J Nurs Sci 1997;2:1-6. 9. Travis SS, Steele L, Long A. Adult day services in a frontier state. Nurs Econ 2001;19: 62-7. 10. Dabelko HI , Balaswamy S. Use of adult day services and home health care services by older adults: a comparative analysis. Home Care Serv Q 2000;18(3):65-79. 11. Raehl C, Bond CA, Woods, T, Patry RA, Sleeper R. Individualized drug use assessment in the elderly. Pharmacotherapy 2002;22:1239-48. 12. Jennings-Sanders A. Examining medication knowledge and behavior of older African American adult day care clients. J Black Nurses Assoc 2001;12(2):23-9. 13. Nelson J. Factors influencing care expressions, patterns and practices in adult day care [dissertation]. St Louis: University of Missouri, 2001, p. 179. 14. Katz S. Studies of illness in the aged. JAMA 1963;185:914-19. 15. Lawton M, Brody E. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-86. 16. Kane R, Ouslander J, Abrass I. Essentials of clinical geriatrics. New York: McGraw-Hill; 1994. 17. McKenry L, Salerno E. Mosby’s pharmacology in nursing. 20th ed. St Louis: Mosby; 1998. 18. Potter PA, Perry AG. Basic nursing: a critical thinking approach. 4th ed. St Louis; Mosby; 1999. 19. Lubben I. Assessing social networks among the elderly populations. Fam Community Health 1998;11(3):42-52. 20. Kane R, Ouslander J, Abrass I. Essentials of clinical geriatrics. 3rd ed. New York: McGraw-Hill; 1994. 21. Nutritional Self-Assessment. In: Stanhope M, Knollmueller R, editors. Handbook of public and community health nursing practice. St Louis: Mosby; 2001. p.259-60.
ANDREA JENNINGS-SANDERS, DrPH, RN, is an Associate Professor in the School of Nursing at Cleveland State University, Cleveland, Ohio. 0197-4572/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2004.06.021
232 Geriatric Nursing
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Number 4
Adult
day care services are community-based group programs designed to support adults’ personal independence by promoting their social, physical, and emotional wellbeing through an individual plan of care. Nurses are in a prime position to care for this population because they deliver holistic care and promote health. Scant literature is available that addresses how nurses provide care for this population. The purpose of this article is to describe how nurses can care for the adult day care population and to present an illustrative case study that demonstrates how nurses can positively affect the health of older adult day care clients. (Geriatr Nurs 2004;25:227-32)
July/August 2004
227
T
he population of older Americans is growing, with the Ritchie7 conducted a qualitative study to explore older number of Americans older than 85 years increasing adults, caregivers, and nurse perceptions regarding adult faster than any other group.1 Seeking cost-effective day care. Older adults suggested social, physical, emotionways to help keep this population in their communial, functional, and environmental considerations as a platties and out of institutions is essential. Utilizing adult form for implementing adult day care programs. The nurse day care centers is a venue that allows older adults to participants suggested that the adult day programs include remain in their community and avoid institutionalization. A client and family health education programs. Caregivers recent study by Partners in Caregiving found that there is a suggested that adult day care programs have a respite progrowing need for more adult day care centers, citing that gram to alleviate caregiver stress. All participates agreed adult day care systems have not kept up with the aging popthat adult day care services were essential to the health and ulation growth.2 Adult day care services are communitywell-being of older adults and their caregivers. based group programs designed to support adults’ personal Travis8 analyzed the development of adult day care independence by promoting their social, physical, and emonursing services and described the need for the nursing tional well-being through an individual plan of care.3 This profession to be more proactive in delineating skills and plan of care encompasses services such as transportation, knowledge requirements for nurses practicing in adult day social services, meals, nursing care, personal care, counselcare centers. The author noted that the little information ing, therapeutic activities, and rehabilitation therapies. Adult known about the provision of nursing services in adult day day care is reimbursable through Medicaid, and a sliding fee care came from various national surveys such as the scale is available for those who do not qualify for Medicaid National Adult Day Care Survey. Travis et al9 also exambenefits. Other funding sources include private pay, foundained the characteristics of participants in and providers of tions, and long-term care insurance. adult day care services in centers throughout the state of There are two primary models of adult day care: the Oklahoma. Their findings revealed that the majority of medical model and the social model. The medical model participants had limited communication deficits and low includes services offered by an array rates of incontinence, but notable cogof professionals who administer care nitive impairment. Discharge data from to adult day care clients; these may adult day care programs suggested that Adult day CARE is REIMBURSABLE include on-site registered nurses, participants required more intense medthrough MEDICAID, and a speech therapists, occupational therical or supportive care (or both). apists, physical therapists, social Dabelko10 compared adult day sersliding FEE scale is AVAILABLE workers, and registered dieticians. vices and home care users on the indiThe social model stresses social cators of personal characteristics, physfor those who DO NOT QUALIFY activities, maintenance of client ical health, mental health, and social for MEDICAID benefits. functioning, nutrition, and recrenetwork contacts. Results indicated that ation for adult day care clients. adult day care users were younger, had Some adult day care centers use the greater cognitive impairment, had more medical model, and others use the social model or a comsocial contacts, and needed more supervisory assistance bination of both models.4 with activities of daily living. The authors suggested that strategies encompassing integrated care models addressL I T E R AT U R E R E V I E W ing physical, mental, and social needs of older adults in A study of adult day services was conducted nationboth the home health care setting and adult day care setwide.5 The study found that the average age of the adult ting are needed. day care consumer was 72 years, and over one-half of all Raehl11 found that seniors’ ability to take oral prescripof the participants had some cognitive impairment. Fiftytion medications safely correlated with age, gender, socioefive percent of the participants lived with an adult child or conomic status, education, cognitive impairment, depresspouse. The National Council on Aging6 conducted a sion, and drug self-management in 3 retirement communistudy examining the need of health and supportive serties and 1 adult day care center. Results indicated that older vices programs in community-based programs such as adults’ ability to take oral prescription medications safely adult day care centers. The results of this study indicated was affected by cognitive function and socioeconomic stathat there is a great need for more programs in adult day tus. A Med Take test was administered to all clients to evalcare centers that target social support, caregiving, physical uate dosage, indication, food or water congestion, and regidisability, and chronic disease self-management. men. Jennings-Sanders12 examined medication knowledge Based on the findings from these studies, care that and behavior of older African American adult day care encompasses social support and management of chronic clients. Findings from this study suggested that there were diseases is needed. At present, there are some adult day care many factors affecting medication regimen compliance centers that utilize nurses, but little has been published on such as caregiver noncompliance, lack of communication the nurse’s role in providing nursing care to this population. with physicians, physical limitations, high costs of medica-
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tions, and utilization of home remedies. The author recomchallenging. These behaviors may include confusion, mended that nurses educate clients about their medications, aggression, hoarding, sundown syndrome, and wandering. be a client advocate, and provide case management to The Dementia Assessment Tool16 measures loss of intelincrease adherence in medication regimens. Nurses could lectual functioning and memory over time. After utilizing do continuous medication assessments and serve as a liaithe tool and consulting with a physician, the nurse will son between the pharmacist and physician and the client to know what type of education and support is needed for the decrease medication adherence problems. client and their caregiver. Nelson13 conducted an ethnographic study to establish Medication Assessment Tool a knowledge base for a practice model of culturally congruent adult day care. The study examined kinship, social, Adult day care clients suffer from many chronic disspiritual, and cultural factors. The data revealed many simeases and therefore use more medications than any other ilarities in the kinship, social, group. The How to Assess the “At spiritual, and cultural factors Risk” Geriatric Client Tool17 asks DATA revealed many similarities in influencing the perceptions of the client to 1) give a complete caring among adult day care cenmedication history; 2) make a list the KINSHIP, SOCIAL, SPIRITUAL, and ter clients, family members, staff of each medication, noting its members, and volunteers. The name, strength, and directions; 3) CULTURAL factors INFLUENCING the analysis also revealed that there identify all physicians prescribing PERCEPTIONS of CARING among adult was substantial congruence in the the medication; 4) question care expressions, patterns, and clients about their self-medicaday care center CLIENTS, FAMILY practices in the centers and tion practices; and 5) describe clients’ homes. The findings from any limitations that may impair members, STAFF members, and this study sheds additional light safe, self-administration of mediVOLUNTEERS. regarding a practice model of culcations. The information from turally congruent adult day care this tool allows the nurse to idenfor nurses working in adult day care centers. tify any problems affecting medication adherence. P R O V I D I N G C A R E T O T H E A D U LT D AY C A R E P O P U L AT I O N Assessment Strengths and weaknesses should be identified for each adult day care client. Each client has their own unique set of circumstances. The identification of strengths and weaknesses can be done using assessment tools readily available in the literature. The following examples of assessment tools may be useful for nurses developing effective plans of care for adult day care clients.
Activities of Daily Living and Instrumental Activities of Daily Living Assessment Tools The assessment of the client’s ability to perform activities of daily living provides the nurse with data to indicate the client’s self care ability. Katz14 developed the Index of Independence in Basic Activities of Daily Living, which is based on an evaluation of the functional independence or dependence of clients in feeding, bathing, dressing, toileting, transferring, and continence. The Instrumental Activities of Daily Living Assessment, developed by Lawton and Brody,15 has 8 categories of a client’s level of functioning: 1) using the telephone, 2) shopping, 3) food preparation, 4) housekeeping, 5) laundry, 6) using a mode of transportation, 7) responsibility for own medications, and 8) handling finances.
Dementia Assessment Tool Dementia can result in behaviors that caregivers find July/August 2004
Multicultural Assessment Tool Nurses need to be aware that older adult day care clients are influenced by their culture, and those cultural differences can adversely affect the relationship between the client and health care provider. The Multicultural Nursing Assessment Tool18 explores various factors (i.e., cultural, psychologic, sociologic, biologic, and physiologic). This instrument helps the nurse understand the client’s values, attitudes, and beliefs about causes of health and illness. For example, older African Americans may believe in folk medicine or home remedies and may prefer to use these methods rather than prescribed medications.
Social Network Assessment Nurses should include a social network assessment as a regular part of their client health assessment. Those adult day care clients with little or limited social networks may be at risk in adhering to their health care regimen. The Lubben Social Network Scale19 explores family networks, social (friends) networks, confidant relationships, helping others, and living arrangements.
Environmental Assessment It is important to conduct an environmental assessment at the client’s home. Older adults are often injured in their homes, and injuries such as falls may lead to additional health problems or worsen existing conditions. Many of these injuries result from hazards that are easily overlooked and avoidable. Nurses should use environmental 229
checklists to detect hazards in the homes of adult day care clients. The Environmental Assessment for the Elderly Tool20 addresses physical hazards in and outside the home and assesses any signs of neglect in the home. An in-home assessment is critical to a comprehensive plan.
Nutritional Assessment Nutritional status has a major impact on a person’s health. The Nutritional Self-Assessment Tool21 is geared toward individuals older than 65 years. It is based on key factors that may represent undernutrition and malnutrition. This tool can be utilized by the adult day care client (as well as the caregiver), who can then ask the nurse for further health advice as needed.
ically discussed and reevaluated with both the client and caregiver. Realistic time frames should be preestablished for each goal. If goals have not been met, new goals should be formed. Evidence of positive outcomes may include increased knowledge, increased self-care, increased satisfaction with nursing care, increased quality of life, and increased satisfaction of adult day care services. The following case study describes the multiple issues that can confront an adult day care client. Ways in which nurses can have a positive impact on the health of a client in adult day care are described.
CASE STUDY Mrs. S is a 72-year-old African American widow. According to the adult day care staff, she is alert and oriPlanning ented with no cognitive impairment. During the previous Planning involves establishing short- and long-term year, she attended an adult day care center 5 days each goals based on the information found in the needs-assessweek. The center is based on a social model in which ment phase. These goals should be mutually agreed on by social activities, socialization, and recreation are the the client and caregiver and have a designated time frame. focus. Mrs. S states that most of her friends have either It is during this time that other interdisciplinary team moved away or are deceased. She states that she enjoys the members are incorporated into the plan of care. Ideally, activities at the center and has developed a few friendinterdisciplinary team members may include a physician, ships. Mrs. S states she has been depressed lately, howeva nurse, and personnel from the adult day care center—for er, because of the recent death of her husband. She has example, adult day care aide, recrearthritis, diabetes, and hypertenational aide, and social worker—as sion and takes multiple medicaEvidence of POSITIVE OUTCOMES well as a family member, caregiver, tions for these conditions; she physical therapist, occupational states that she is taking 3 medicamay include increased KNOWLEDGE, therapist, speech therapist, recretions for her hypertension. Mrs. S. increased SELF-CARE, increased further states that she becomes ational therapist, podiatrist, dentist, dizzy when she takes all 3 of her and pharmacist. SATISFACTION with nursing care, hypertension medications. She Implementation was recently diagnosed with diaincreased QUALITY OF LIFE,and betes and states that she does not When implementing the plan of increased SATISFACTION of adult day know much about the disease. care for the adult day care client, Mrs. S finds it is somewhat diffithe nurse assumes various roles, CARE SERVICES. cult to perform all of her activities including that of clinician, health of daily living. She needs assiseducator, and case manager. As tance with instrumental activities of daily living. In terms clinician, the nurse may perform physical exams and conof physical limitation, she has limited use of two of her duct health screenings (e.g., cholesterol, blood pressure, fingers on her dominant hand because of arthritis. She also and blood glucose). The nurse as a health educator has the suffers from arthritis in her right foot, which causes a responsibility to educate the client and the caregiver about slight limp. She uses a cane to keep her balance. Mrs. S the client’s condition(s). Providing knowledge about availstates that her daughter provides emotional support and able resources in the community is also important for the handles her finances, but at times the daughter spends adult day care client and their caregiver. As case manager, money for “other things,” leaving Mrs. S unable to afford the nurse coordinates delivery of care, provides referrals, all of her medications. She uses home remedies for her and serves as an advocate for the adult day care client. The arthritis. Mrs. S lives alone in a large house and is on a nurse may need to coordinate care if the client is utilizing fixed income. Her daughter visits on a regular basis. She multiple health care services. In terms of providing referhas two other children who live across town but has limitrals, a client may have trouble chewing food due to malfunctioning dentures. In this instance, the nurse would ed contact with them. Mrs. S is overweight and buys most refer this client to a dentist. of her food from a small, nearby grocery store where salty, fatty, and sweet foods are sold. It is not easy to get transEvaluation portation to go another store. A registered nurse works 1 day a week at Mrs. S’s adult Evaluation is an ongoing assessment of the client’s day care center to assess the problems that clients have in short- and long-term goals. These goals should be period-
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managing their chronic conditions. In the assessment home remedies) is key. Providing information about phase, strengths and weaknesses for this particular client how to manage Mrs. S’s chronic conditions—diabetes, are delineated. arthritis, and hypertension—is also needed. A special Strengths: The client is alert and oriented without any emphasis should be placed on diabetes because the cognitive impairment. She attends adult day care 5 days a client is newly diagnosed. The client should be educatweek, and the center she attends seems appropriate ed about nutritious foods associated with effectively because it focuses on socialization. She has developed a managing her diabetes and hypertension. Educational few friendships at the center. Her daughter provides emointerventions can take place on an individual basis or tional support to her and visits on a regular basis. A registhrough focus groups. tered nurse is available on a regular basis to clients at the As case manager, the nurse will be a client advocate day care center. and provide referrals. The nurse acts as a client advocate Weaknesses: The client is depressed because of the when she speaks to the physician concerning the 3 medirecent death of her spouse. She has 3 chronic conditions, cations the client takes to control her hypertension and the takes multiple medications for each, has a knowledge deficit dizziness that she experiences. In addition, a physical about her diabetes, and needs assistance with her ADLs and therapy referral should be requested regarding the immoIADLs. She has altered mobility in her fingers and foot bility of the client’s 2 fingers and the slight limp in her because of arthritis. Her daughter handles her finances but foot. A medication organizer for the client to encourage a spends the money for “other things,” and the client is thereregular medication regimen would be useful. A list of fore unable to buy all her medications. She uses home sources where functional aides (e.g., hand grippers, dressremedies for her arthritis. Contact with her other two chiling aide sticks, or jar openers) can be purchased and infordren, who live across town, is limited. She is overweight mation on Medicare coverage for such items should be and does not have adequate transportation. offered to the client. The nurse should ask the client about Assessment tools mentioned previously were useful for the “other things” that the daughter is buying that appear the nurse to determine the extent of each of the weaknesses to be preventing the purchase of medications. Alternative identified in this case study. In the planning phase, shortways to manage the client’s finances should be discussed. and long-term goals should be set according to the weakThe daughter should be asked about her perceptions of nesses identified. An example of a what barriers exist in terms of short-term goal for the knowledge self-management of her mother’s The NURSE is ESSENTIAL because she deficit would be for the client to be chronic conditions. The nurse able to list 3 signs of hypoglycemia should ask the client if other famor he can ASSESS WEAKNESSES and when the nurse returns 1 week later. ily members are available to help An example of a long-term goal Mrs. S manage her conditions. STRENGTHS in each adult day care would be having the client attend It may be necessary for the CLIENT with the ultimate GOAL of nurse to make other referrals. monthly focus-group sessions These may include a home care regarding diabetes for at least 6 producing POSITIVE client OUTCOMES. agency to assist the client at months. The nurse, client, and family home, a pharmaceutical assismember or significant other should tance program, a drugstore delivmutually set these goals. ery program, a support group for bereavement and diaInvolvement of an interdisciplinary team would benefit betes, transportation services (e.g., to grocery stores and the client in this case study. The nurse is essential because physician appointments) offered by the adult day center, she or he can assess weaknesses and strengths in each adult and Adult Protective Services for reporting possible finanday care client with the ultimate goal of producing positive cial elder abuse. client outcomes. The personnel at the day care center (adult In the evaluation phase, short- and long-term goals day care director and recreational aides) can continue to regarding the weaknesses identified in the case study, observe the client’s behaviors and note any differences over should be evaluated and reevaluated by the nurse, client, time. The recreational aides also can consistently involve family member, and other members of the interdiscithe client in activities to increase socialization. A physical plinary team. If goals have not been met by the specified therapist may be helpful to the client in terms of prescribtime, new goals should be formed. ing specific hand and foot exercises. The physician is needed to reevaluate current medication prescriptions and monCONCLUSION itor health conditions. A social worker may be needed to Nurses working in adult day care centers can have a siginvestigate possible financial abuse. All family members nificant impact on the health of adult day care clients,8,12 should be encouraged to participate in the plan of care. who are burdened with many physical, mental, and social In terms of health education, educating the client deficits. Their roles as clinician, health educator, and case about her medications (actions, side effects, and intermanager are necessary when caring for this population. actions with other medications and with herbs and July/August 2004
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Assessment tools are essential to determine the extent of each weakness identified for the adult day care client. Nurses serving the adult day care population8,12 need to develop a clear definition of what their practice entails and describe the skills needed to work in this subspecialty.8 To define adult day care nursing further, nursing faculty will need to incorporate clinical experiences at adult day care centers for their nursing students. Future nursing research needs to focus on the positive outcomes that are a direct result of nursing care in adult day care settings. The ultimate goal is to improve the quality of life for the adult day client and maintain the highest level of independence. REFERENCES 1. Administration on Aging. A Profile of Older Americans. 2002. Available at: www.aoa.gov/prof/Statistics/profile/profiles.asp. Accessed May 2004. 2. Partners in Caregiving: The Dementia Services Program. 2003. Available at: www.rwif.org/reports/npreports/partnerse.htm. Accessed January 2003. 3. National Adult Day Care Services Association. Mission statement on adult day care. 2002. Available at www.nadsa.org. Accessed February 2003. 4. Gaugler J, Zarit S. The effectiveness of adult day care services for disabled older people. J Aging Soc Policy 2001;12(2):23-46. 5. The Robert Wood Johnson Foundation, National Study of Adult Day Care Services 2001-2002. Available at www.rwjf.org/news/special/adultday servicesSummary.jhtml. Accessed July 2004. 6. National Council Report on Aging. National Survey of Health and Supportive Services in the Aging Network. www.ncoa.org. Accessed May 2003 7. Ritchie L. Adult day care: northern perspectives. Public Health Nurs 2003;20:120-34. 8. Travis SS. Adult day services: an emerging nursing subspecialty in community based care. J Nurs Sci 1997;2:1-6. 9. Travis SS, Steele L, Long A. Adult day services in a frontier state. Nurs Econ 2001;19: 62-7. 10. Dabelko HI , Balaswamy S. Use of adult day services and home health care services by older adults: a comparative analysis. Home Care Serv Q 2000;18(3):65-79. 11. Raehl C, Bond CA, Woods, T, Patry RA, Sleeper R. Individualized drug use assessment in the elderly. Pharmacotherapy 2002;22:1239-48. 12. Jennings-Sanders A. Examining medication knowledge and behavior of older African American adult day care clients. J Black Nurses Assoc 2001;12(2):23-9. 13. Nelson J. Factors influencing care expressions, patterns and practices in adult day care [dissertation]. St Louis: University of Missouri, 2001, p. 179. 14. Katz S. Studies of illness in the aged. JAMA 1963;185:914-19. 15. Lawton M, Brody E. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-86. 16. Kane R, Ouslander J, Abrass I. Essentials of clinical geriatrics. New York: McGraw-Hill; 1994. 17. McKenry L, Salerno E. Mosby’s pharmacology in nursing. 20th ed. St Louis: Mosby; 1998. 18. Potter PA, Perry AG. Basic nursing: a critical thinking approach. 4th ed. St Louis; Mosby; 1999. 19. Lubben I. Assessing social networks among the elderly populations. Fam Community Health 1998;11(3):42-52. 20. Kane R, Ouslander J, Abrass I. Essentials of clinical geriatrics. 3rd ed. New York: McGraw-Hill; 1994. 21. Nutritional Self-Assessment. In: Stanhope M, Knollmueller R, editors. Handbook of public and community health nursing practice. St Louis: Mosby; 2001. p.259-60.
ANDREA JENNINGS-SANDERS, DrPH, RN, is an Associate Professor in the School of Nursing at Cleveland State University, Cleveland, Ohio. 0197-4572/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2004.06.021
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