Special considerations for the nursing home resident

Special Considerationsfor the Nursing Home Resident Nursing responsibility for drug administration and patient monitoring is perhaps most extensive in this setting.

residents exaggerate the slightest ache or pain to get attention. If so, she encourages staff and visitors to increase their interactions with such r e s i d e n t s . r a t h e r than automatically seeking a drug remedy. She learns that some residents are not sufficiently aware of their functioning to report unusual drug efCYNTHIA WALLACE fects promptly, and therefore she monitors them with particular T h e principles of therapeutic drug administration apply wherever an care. older person lives and whenever he T h e nursing home nurse also or she receives medication. But finds that many residents deny there are differences in managing symptoms 9 or try to disguise them medications in a long-term care fabecause they fear hospitalization. cility. At a lifetime care residence, for exResidents in this setting tend to ample, a man who had cerebral be more dependent and to have palsy but managed most of his own more chronic problems or more secare hid his pajama pants and rious disabilities than older men briefs when he saw dark stains on them. and women living in the community. Their very frailty brought most 9 Observing that he seemed less of them to the skilled nursing, inpeppy than usual and looked pale, termediate care, or health related his nurse arranged for a complete blood count. His hemoglobin was 9 facility. Experienc e has taught me that they need nurses who are espegrams. Close questioning led to a cially sensitive and knowledgeable check of his bureau drawers, which about the legal and clinical aspects disclosed the stained clothing. Furof drug administration(l). ther tests resulted in a diagnosis of A second difference about nursbleeding duodenal ulcer, for which he was successfully treated. ing home practice, and it is a disIdeally, nurses and physicians tinct advantage, is that the nurse knows each resident well because of collaborate daily in any setting in delivering care. In the S N F or I C F , their day-by-day contact, often on a permanent basis. Familiar with however, the nurse is in daily contact with the elderly resident but each resident, the nurse can iecogthe physician may see the resident nize their responses to medication quickly and interpret changes in as infrequently as once in 30 days, their behavior with considerable inand must rely heavily on the nurse's assessments. Together, they sight. create the plan of care. Drug theraOccasionally the long-term care py is often a vital part of that nurse discovers that a few elderly plan. Before becoming the administrator of The nurse's coordination of a resMorningside House Nursing Home Co., ident's plan of care begins when a Inc., Bronx, N.Y., Cynthia Wallace, R.N., drug history is taken from the resiM.A., was its director of nursing.

dent, the family, or both. This includes all the drugs the person has been taking at horn'e, including over-the-counter preparations, the dose, and the frequency. If the resident has brought medications with him, he is asked to surrender them and assured that he will receive them if prescribed. This is a time to counsel friends and family n o t to bring O T C medications to their relative because they may mask symptoms or interfere with treatment. Most people accept this counsel 9 if the nurse explains the inherent dangers carefully and if the resident does indeed receive appropriate medication in a timely fashion. Drug prescriptions are reviewed by the nurse for accuracy and completeness. If a prescription is not clear or the dose seems unusual, the nurse clarifies it before it is transcribed o n the p h a r m a c y requisition, medicine ticket, and care plan. In an emergency a verbal prescription can be given, but only to a licensed nurse, pharmacist, or physician. T h e prescription must be recorded and signed immediately by the person receiving it, and it must be countersigned by the physician within 48 hours, with the date and time of signing. Verbal prescriptions for drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1970 are permitted 0nly in a n emergency, and this emergency must be documented in the nurse's not& Every drug is given to achieve a specific result. When the nurse is absolutely clear as to why the drug

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is needed and what its desired resuits should be, the drug regimen is entered in the resident's care plan. At our facility, the specific need is stated as the problem, the desired results as the goal, and the drug therapy may be the whole or part of the methodology, as illustrated below:

Problem/Need 3q- edema of ankles Goal--eliminate edema

Methodology furosemide (Lasix) 40 mg. PO, OD elevate legs 2 hr. 4 x / d a y

Response Edema decreased to 1-tThe nurse monitors the resident's response on a daily basis, checking for the desired results and for possible undesirable side ef"fects. The nurse becomes familiar with the evidence of an undesirable side effect by referring to the Phy-

sician's Desk Reference, American Hospital Formulary Services, and recent professional literature, or by consulting the pharmacist. Signs or symptoms of any undesirable side effect dictate withholding the drug and notifying the physician. The elderly resident, like the hospitalized patient or communitybased aged person, may be treated by several specialists--an ophthalmologist, internist, a dermatologist, podiatrist, and so on. If so, it is essential that the nurse review all medications to ensure that what is prescribed by one specialist is not contraindicated by the orders of another. Nursing vigilance is particularly critical in the !ong-term facility, which may have no in-house pharmacist or physician. Laboratory studies are es'sential to follow residents' responses to drug therapy. When a resident is being treated for congestive heart failure with a diuretic, blood electrolytes and a blood urea nitrogen or serum creatinine are measured at least every six months. For diabetes mellitus, blood glucose levels are monitored at least every three months and urine is tested for glu-

cose and acetone at least four times weekly. When interpreting lab results, remember that normal ranges for the elderly vary widely, and that each person is her or his own best norm(2). Report abnormal lab resuits immediately so that the drug therapy may be modified appropriately. At least monthly the nurse reviews the total drug regimen of all residents and documents their responses. This documentation reflects achievement or nonachievement of the goal: Based on this assessment, nurse and physician establish a new.plan of care, once again defining the problem, the goal, and the method to achieve it. Dos e scheduling is another mat-

When interpreting lab results, remember that normal ranges for the aged vary Widely, and that each person is his own best norm.

ter to plan carefully. Medications specifically formulated to produce prolonged action provide more uniform and, therefore, more effective blood,levels. Residents need to take fewer doses, and less staff time is required to administer them. Because products identified as sustained release, prolonged action, repeat action, spansules, or Ternbids are specially formulated, care is taken not to alter their design by crushing them or administering them too close together. A q l2h schedule may be more appropriate than a twice daily, or 9:00 A.M. and 5:00 P.M., schedule. Examples of these long-acting drugs include 9 isosorbide dinitrate time release (Isordil Tembids 40 m g . ) - prophylaxis in angina pectoris 9 nitroglycerin time release (Nitro-BID 2.5 mg.)--prophylaxis in

the treatment of angina pectoris 9 quinidine gluconate sustained release (Quinaglute D u r a - T a b s ) ~ used to treat premature atrial and ventricular contractions, paroxysmal atrial tachycardia and fibrillation, and atrial flutter. Give the major and minor tranquilizers, such as haloperidol (Haldol), thioridazine (Mellaril), doxepin (Sinequan), thiothixene (Navane), diazepam (Valium), and chlordiazepoxide (Librium), at 9:00 A.M. and 9:00 O.M. to produce more sedation at bedtime and less at midday because of their tendency to accumulate in the elderly. But always evaluate each resident's situation individually. Be alert to the very earliest sign or symptom of extrapyramidal side effects in a resident who is taking a m a j o r tranquilizer (see the Portnoi/Johnson article for a discussion of tardive dyskinesia). Always employ nursing measures to promote relaxation and encourage the daytime activity that induces healthy fatigue and better sleep(3). Use PRN medication wisely. The following article by Carol Miller discusses PRN drug management in detail.

Stop Orders Most medications are governed by automatic stop orders that are dictated by .local and federal regulations and institutional policy. Typically, in the SNF, all drugs are stopped after 30 days, and in a H R F after 60 days, unless reviewed and represcribed by a physician. The nurse familiarizes herself with tlae institution's stop-order policy, to avoid giving a drug that has been cancelled automatically. While it is the physician's responsibility to continue or change a prescription, the nurse often assists by notifying the physician of an automatic stop order before the last dose. Drugs and biologicals are administered only by licensed nurses, physicians, or nurses' aides who have completed a state-approved course in drug administration. The same procedures for verifying drug tickets against the physicians' prescriptions, for identifying the resi-

dent before administering a drug, and for its p r o m p t recording are followed in the long-term care facility as in a hospital. Drugs and biologicals are administered as soon as possible after the dose is prepared, and by the person who prepared the dose unless, of course, the medication is in a single unit dose package. Self-Medication

One of the most difficult adjustments for an older adult is the surrendering of his or her bottle(s) of pills on entering a long-term care facility. For some residents, however, self-administration is allowed after their ability to do so has been determined. Self-medication promotes independence and residents' psychological well-being by allowing t h e m more control of their care. T h e nurse's assessment of the resident's ability to m a n a g e self-medication guides the physician in writing the order to permit it. W h e n the resident has been d e e m e d capable to self-medicate, the nurse obtains o

the drug(s) from the p h a r m a c i s t and gives it to the resident. She explains the purpose of each medication, why it is needed, how to take it, and the consequences of failing to take it. Periodically, the nurse checks to determine that the resident is completely a w a r e of the drug's purpose, the desired results, and that he or she is indeed taking each dose. S o m e elderly residents need m e m o ry aids to maintain compliance, such as those described by P a v k o v / Stephens in P a r t One of this feature ( N o v e m b e r / D e c e m b e r , 1981, pp. 4 2 7 - 4 2 8 ) . I f an intercurrent illness or need for surgery necessitates the resident's transfer to an acute-care hospital, the nurse transmits a complete list of that person's current medications. All of those drugs m a y be cancelled on hospital admission. However, m a n y drugs m a y continue free and active for some time because of their prolonged half-life in the elderly or slower excretion due to renal i m p a i r m e n t ( 4 ) . A tele-

phone conference with dent's hospital nurse is c helpful. In sum, the nurse's part in drug therapy is highly i m p o r t a n t in S N F s , H R F s , and I C F s . Because physicians visit infrequently, because there are fewer professional resources than in a hospital, but, most important, because the residents are frail, nurses strive to recognize changes in their b e h a v i o r or laboratory findings and to assess the relationship of these c h a n g e s to their drug therapy. E a r l y recognition of a possible d r u g - r e l a t e d condition can m e a n the difference between life and death. T h e nurse is not m e r e l y conscious that she is seeing a c h a n g e . S h e does not simply d o c u m e n t its occurrence. She investigates t h e cause of the change and acts on h e r findings. W h e n e v e r possible, she carries out nursing m e a s u r e s to reduce the elderly person's n e e d for medication or to s u p p l e m e n t its beneficial effect. GN References: See last page of feature.

PRN Drugs... to Give or Not to Give? Managing "as needed" drugs wisely is a demanding task, especially for the nursing home resident. C A R O L A. M I L L E R Each time a discretionary, or P R N , drug is given or not given to a patient it is a nurse who makes the decision to give or withhold it. This decision-making responsi-

bility is exceedingly important in nursing homes for two reasons. First, d a y - t o - d a y decisions regarding most patient care, including drug therapy, are based on nursing observation, j u d g m e n t s , and documentation. Second, a large percentage of drugs for nursing home residents are ordered o n an "as needed" basis rather than a set dosage schedule(1 ). A responsible decision for each P R N drug administration is based on thoughtful consideration of the drug action, its possible adverse ef-

fects, and the nursing goals f o r t h e patient. H e r e I will discuss t h e s e three considerations, using t h e e x a m p l e of the P R N t r a n q u i l i z e r . I t is one of the categories o f P R N drugs that is prescribed m o s t o f t e n for nursing home p a t i e n t s ( 2 ) . Carol A. Miller, R.N., M.S.N., is clinical

nurse specialist, Medical Geropsychiatric Unit, Lutheran MedicaiCenter, Cleveland, Ohio. This article is based largely on information collected for her thesis, "The Prescription and Administration of Selected Drugs in a Nursing Home." An abstract of her study appears in the box titled " P R N Psychotropies.'"