NURS 306: Week 10 - Keeping me where I want to be

What does aging in place mean?

- Living in one's own home or community

- Maintaining independence and autonomy

- Having access to health and social supports

- Remaining safe and socially connected

What is healthy aging?

The process of developing and maintaining the functional ability that enables well-being in older age.

What is included in functional ability?

- Meeting basic needs

- Learning and decision-making

- Mobility

- Relationships

- Contributing to society

What are some of the benefits of aging in place?

- Preservation of identity and familiarity

- Stronger social networks

- Greater sense of autonomy

- Potential cost savings

What are supports needed for aging in place?

- individual level supports

- Social and community supports

- Housing and environment

- System-level infrastructure

What is a continuum of care?

A coordinated range of services that respond to changing needs over time.

What is a nurse's role in the continuum of care?

- Assessing functional status and risk

- Supporting safe discharge planning

- Coordinating community resources

- Educating patients and caregivers

- Advocating for person-centered care

What does transition mean?

A passage from one life phase, health condition, or care setting to another, requiring adaptation.

What are some causes of frequent transitions in older adults?

- Acute illness

- Chronic disease exacerbation

- Functional decline

- Caregiver strain

What does frequent transition increases risk for in older adults?

- Communication breakdown

- Medication discrepancies

- Hospital readmissions

- Functional decline

- Emotional distress

Hospitalization is not neutral for older adults and can accelerate vulnerabiltiy if not proactively managed (True/False).

True

1 multiple choice option

What are some things that older adults can experience while hospitalized?

- Acute illness or worsening conditions

- Deconditioning

- Cognitive changes

- Polypharmacy

- Emotional stress

It's ideal to keep hospital stays short for older adults because there's no associated lasting functional decline in that case (True/False).

False

1 multiple choice option

What are some nursing considerations in hospital transitions with older adults?

- Early ongoing comprehensive assessment

- Medication reconciliation

- Delirium screening and mobility decline

- Caregiver assessment and safety needs

- Interdisciplinary coordination

- Patient and caregiver education

- Timely follow-up and community supports

What is independence?

The ability to perform ADLs and make decisions without assistance.

What is dependence?

Reliance on others for care, decision-making, or support in daily activities.

What is interdependence?

A balanced relationship between independence and dependence.

What are some assessment tools used for transition risks?

- WHODAS 2.0

- ISAR

- MAPLe

What is WHODAS 2.0?

- Assesses functional ability and disability

- Can be used in any setting

- Identifies support needs

What is ISAR?

- Assesses risk for adverse outcomes

- Mainly used in ED/acute care

- Screens high-risk older adults

What is MAPLe?

- Assesses the priority for care allocation

- Mainly used in home care/LTC

- Guides resource allocation

What are some evidence-based interventions for transitions?

- Structured discharge planning

- medication reconciliation and review

- Patient and caregiver education

- Early mobilization and functional support

- Post-discharge follow-up and monitoring

What are some nursing challenges and barriers to transitions in care?

- Fragmented communication

- Time constraints

- Limited education opportunities

- Limited resources

- Cultural and language barriers