Health Articles

Nurses play a vital role in discharge planning, which begins at admission and continues through discharge. Nurses help determine when discharge is safe and which setting is most appropriate. Effective discharge planning speeds discharge, decreases the likelihood of readmis-sion, identifies less expensive care alternatives, and helps increase patient satisfaction. One example of discharge planning standards, developed by the Boston Regional Continuing Care Nurses Association, is shown in TABLE 23-2.
Before the patient is discharged or transferred, effective communication between settings helps ensure continuity of care. In most cases, a nurse caring for a hospital patient should call the nurse who will care for the patient after discharge in a nursing home, at home, or through a home care service. The appropriate transfer form should contain complete, accurate information, including resuscitation status, cognitive and physical function, medications, follow-up appointments and studies, and the names and phone numbers of a nurse and physician who can provide additional information. When a patient is transferred to the hospital from a nursing home, the nursing home nurse should inform the admitting nurse about the patient’s cognitive and physical status, resuscitation status, medications and medication allergies, and family support.

In most patient care settings, the nurse explains tests and procedures to the patient and family. For example, a gastroenterologist may use diagrams in describing an endoscopy to obtain informed consent, but the nurse then elaborates, explaining the procedure based on the patient’s ability to understand and retain the information. Nurses also develop patient education pamphlets containing pertinent information and phone numbers in case questions arise. Nurses regularly demonstrate self-care procedures to patients and then have the patients perform the procedures as the nurses observe. Such procedures include irrigating a new colostomy, injecting insulin, and providing wound care for a pressure sore. Ongoing evaluation of the elderly patient’s ability to learn new information or behavior should be documented, along with an assessment of the support available in the patient’s environment, whether it is the home, a nursing home, or the intensive care unit.
Determining the best teaching method for a particular patient can speed the process dramatically. For instance, some elderly patients learn best when they have written or printed material; others prefer videotaped information. The nurse can tell the multidisciplinary team which methods the patient prefers, so an appropriate unified approach can be tailored to the patient.
Usually, the nurse sees family members more often than other team members do. Continual, open communication with family members lets them know that their input is valuable. As a result, the nurse is more likely to obtain useful, accurate information about the patient’s home. After discharge, the nurse should continue to be available to the patient and family.

Providing physical and emotional comfort to an elderly patient may include giving relaxing back rubs; providing favorite pillows, treasured pictures, and personal articles; and giving care with a personal touch. During the rare quiet times in an institution when a nurse can give a bed bath or a back rub or even sit and read with the patient, a great deal of information can be exchanged, both verbally and nonverbally. While cost containment is the rule of the day, the importance of providing comfort measures cannot be overemphasized.
Nurses also play a key role in administering analgesics. When standing orders exist, nurses should give analgesics assiduously. Many narcotics have short half-lives and lose their effectiveness within hours; if they are not given on time, pain recurs. Nurses must also monitor patients for pain and then advise physicians about changing doses or administration times. When analgesics are ordered as needed, nurses must decide when to give them. Waiting for patients to ask for pain medication is usually not the best course. Some patients cannot ask; others wait until the pain becomes severe. Nurses may be able to anticipate the need for analgesics either by time or by upcoming events such as a dressing change, turning, moving, or toileting (see also Ch. 12).

Distinct from chronic sleep disorders, sleep problems in the hospital usually stem from worry related to illness, discomfort with unfamiliar surroundings, pain, and environmental noise. Particularly in the hospital, sleep problems may go unnoticed for several days, leading to sleep deprivation and delirium. Obtaining a sleep history, keeping a sleep flow chart, and documenting the patient’s perception of sleeping patterns in the hospital can help in identifying sleep deprivation as the cause of cognitive changes.
Preventing unnecessary noise on the evening and night shifts and unnecessary interruptions, such as those for routine vital signs, may solve the problem. Foods, medications, and therapies should be reviewed for their possible effects on the patient’s sleep; if the nurse suspects one of these factors, the suspicion should be reported to the physician and other team members. Caffeine should be avoided, if the patient is willing to give it up. A medication such as theophylline, which may be prescribed to treat lung disease, can severely disturb sleep patterns. Exercise (though highly unlikely in the hospital) should take place early in the day. Even a simple change such as providing a better mattress can be effective. This intervention may be particularly helpful in patients who become disoriented in a flotation bed. Finally, support from the hospital chaplain, volunteers, physician, or the nursing staff may help ease the anxiety related to being sick (see also Ch. 11).

Delirious and demented elderly patients are at risk for falls, medication errors, communication problems, and nutritional deficits. They may also become uncooperative, noisy, and violent and may be unable to participate in making medical decisions.
Delirium requires a rapid nursing response. It signals serious medical illness and is a grave prognostic sign. Also, a delirious older person can easily fall and break a hip, thrash out and strike a caregiver or another patient, or become extremely frightened. After evaluating the extent and nature of the problem, the nurse should immediately consult the physician to determine which temporary safety measure should be taken, what clinical information should be gathered to determine the underlying cause, and what, if any, medications are appropriate. Frequently, the delirium is iatrogenic. Therefore, the patient’s medications should be reviewed and evidence of hypoxia or other physiologic changes, including cardiac, neurologic, renal, hepatic, or metabolic changes, should be sought. The importance of rapid intervention cannot be overstated. Initially, the most important nursing intervention is to stay with the patient to help alleviate fear and protect the patient from injury (see also Ch. 9 and DELIRIUM in Ch. 90).
In older persons with dementia, the cognitive deterioration has evolved over time. Thus, a history obtained from the family or caregiver will reveal behavioral changes and the ways in which the patient and family have adapted. The nurse should document the routines described by the family and other caregivers and incorporate them into the care plan. Most important, the nurse should document what the family says about the patient’s usual behavior at home, so the team can try to maintain a similar environment and thus avoid triggering behavioral problems. Regular mental status examinations should be performed and documented. A deterioration of cognition or behavior may indicate superimposed delirium (see also DEMENTIA in Ch. 90).

A major cause of morbidity and mortality in the elderly, falls account for most institutional incident reports. Nursing responsibilities include working with other health care team members to prevent falls, document which patients are at high risk, and intervene after falls to determine the extent of injury and to prevent subsequent falls.
Most falls occur during the day when patients are more active and during shift changes. Falls are also common during the night shift when patients who awaken to use the bathroom are confused or disoriented and fewer staff members are available. Nursing care plans should note risk factors for falls, including weakness, altered mentation, proprioceptive problems, and sensory losses. All nursing practice sites should have a plan for preventing or reducing falls; this plan should be part of a quality assurance program.
Specific nursing interventions for preventing falls include using bed rails appropriately, using vest restraints to keep patients in bed, and hiring sitters to observe patients. Sitters can also help ensure that IV lines, nasogastric tubes, and central lines are not pulled out. However, sitters are expensive, and patients may resent having their privacy invaded. An alternative is to place high-risk patients in rooms near the nurses’ station or to seat them in comfortable chairs where they can be constantly monitored.
When physical restraints are ordered, the minimum standard for safe nursing practice includes checking the restraints at least hourly and releasing them every 2 h to prevent circulatory impairment and skin breakdown. Probably most important, this regular checking and releasing reassures patients that they have not been tied up and forgotten. Understandably, patients and families resent the use of restraints without appropriate instruction, support, and documentation that all alternatives have been considered and informed consents have been obtained. Documentation should indicate why restraints have been ordered, under what conditions they will be continued, how they will be evaluated, and when they should be discontinued. When appropriate, the nurse should recommend discontinuing the restraints. Restraints should also require new orders every 3 days so that inappropriate use is not continued (see also Ch. 7).

Eating and feeding problems can often be resolved with meticulous nursing assessment and intervention. These nursing activities are distinct from those of the dietitian or nutritionist, but they are just as essential for adequate patient nutrition.
A patient who is unable to swallow, digest, or absorb sufficient food and fluid taken by mouth requires enteral or parenteral feedings. A patient who can ingest nothing by mouth is at particularly high risk for being inadequately nourished. The nurse should carefully document weight loss, decreased skin turgor, changes in bowel habits (especially diarrhea and constipation), and other early signs of declining nutritional status and promptly report this information to the doctor.
When a patient is not eating adequately, the nurse should assess eating and feeding patterns to find out why. Anorexia may result from illness, depression, poorly fitting dentures, dry mouth, or a dislike of the foods provided. In a busy institution with conflicting schedules, inadequate nutrition may result simply because the patient is a slow eater. Eating problems may also result from difficulties in using eating utensils because of paraplegia, muscle weakness, or neuralgia. In such cases, efforts should be made to improve hand strength and muscle coordination so patients can maintain their ability to feed themselves. The nurse may need to work with a physical or occupational therapist to develop a plan for regular muscle strengthening exercises throughout the day.
In many cases of inadequate eating or feeding, nursing interventions solve the problem. Nurses or nursing assistants may place food or nutritional supplements at the patient’s bedside, dispense frequent small feedings, instruct dietary services to leave meal trays past the usual time for collection, or consult with dietitians to alter the consistency of the diet. When necessary, nurses should reposition patients to prevent choking and should keep patients from returning to bed too soon after eating to help prevent regurgitation (see also Ch. 2).

Preventive nursing measures include instituting a regular toileting schedule using prompted voiding, providing easy and safe access to the bathroom, and planning appropriate timing of diuretics and fluids. When older patients become incontinent, nurse-managed protocols that document patterns of urinary and fecal incontinence and describe therapeutic interventions provide valuable information. For example, information about the bowel patterns of older patients can make a difference between an unwanted outcome (such as a severe impaction or diarrhea from antibiotics and nutritional supplements) and an early, successful resolution.
When urinary incontinence occurs, the nurse must understand the cause to develop an appropriate care plan. For example, when incontinence results from an irreversible neurologic cause, the nurse should minimize discomfort and promote appropriate coping responses. If incontinence is acute and reversible, efforts are directed at the underlying problem. When a patient has an episode of delirium, the possibility of incontinence should be anticipated, and the patient should be taken to the bathroom or offered a bedpan or urinal more often than usual. An indwelling catheter should be used only as a last resort and only as long as necessary. When a patient has an indwelling catheter, the nurse should keep the physician apprised of how long it has been in place and may need to advocate its removal.
For any patient with urinary incontinence, the nurse should keep an incontinence chart; every 2 h, the nurse documents the amount of urine voided, the amount lost because of incontinence, any associated symptoms, and any patient comments. Adult urinary incontinence pads and diapers should be used judiciously because they retain urine against the skin. They are inappropriate substitutes for helping the patient get to the bathroom. Every effort should be made to respect patient preferences regarding the management of urinary incontinence (see also Ch. 15).
An embarrassing problem for older patients, fecal incontinence may result from IV antibiotics, hyperalimentation, or chemotherapy or from delirium or another neurologic disorder. Nurses should strive to recognize fecal incontinence when possible and prevent its complications. If the patient has diarrhea, the nurse must observe closely for fluid and electrolyte imbalance and for dehydration. The fecal material and the continuous wiping may produce excoriations on the buttocks. Before redness or soreness develops, lotion should be applied to the skin. If the patient cannot exert any bowel control, insertion of a rectal tube should be considered. Because fecal incontinence may be a sign of impaction, this diagnosis should be excluded before therapies are initiated (see also Chs. 53 and 55).

A primary objective of nursing practice is preventing skin breakdown. For elderly patients at special risk for such breakdown, the potential problem should be listed in the nursing care plan. Preventive measures include following a regular observation schedule, turning and massaging the patient as appropriate, and using prophylactic bed surfaces, such as sheepskin, special air mattresses, and air-fluidized beds.
Preventing skin breakdown is paramount. Once a pressure sore progresses to stage 2 (partial-thickness skin loss involving the epidermis and dermis), nursing actions must become more vigorous. These actions may include turning the patient regularly, applying the appropriate dressing, continually monitoring the patient, and documenting all nursing care and observations. If a pressure sore progresses to stage 4 (full-thickness skin loss involving extensive necrosis or damage to muscle, bone, or supporting structure), the nurse should include in the care plan interventions for social isolation, depression, pain, and discomfort (see also Ch. 14).

Nurses participate in the management of many geriatric problems: pressure sores, urinary and fecal incontinence, eating and feeding problems, falls, confusion, sleep problems, and discomfort and pain.