Ethical Principles in Healthcare Decision Making for Older Adults, Exams of Nursing

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NR 601 Primary Care of the Maturing & Aged Family

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The following are components of the open disclosure of medical error, except: a. An apology to the injured patient. b. An explanation of the error in lay language. c. A best guess as to why the error occurred. d. An assurance that a full investigation will take place. C Mrs. Gloth is an 84-year-old woman whom you are admitting to the nursing home. Her son takes you aside and tells you that she has metastatic ovarian cancer but has not been told the diagnosis. He asks that you not tell her, because she would "lose all hope and die." Which of the following is an appropriate response? a. Tell the son that you are going to immediately inform the patient of her diagnosis. b. Tell the son that he can count on you to respect his wishes. c. Suggest that you discuss this further after getting to know the patient and family a little better. d. Find out from the son what the family has been telling her about her health, so you will maintain a consistent story. C Dr. Smith is obtaining informed consent from Mr. Jones to perform a colonoscopy, because the patient had blood in his stool and Dr. Smith is concerned that this might indicate the presence of carcinoma of the colon. Mr. Jones is able to recite back to Dr. Smith what a colonoscopy is, how it is done, and that a colonoscopy is performed to look for cancer. He then tells Dr. Smith that he is refusing the procedure; he knows he does not

have cancer because he has not experienced any bleeding. Of the following required elements for Mr. Jones's decision-making capacity, which is impaired? a. Understanding b. Appreciation c. Ability to express a choice B George Hall is a 91-year-old man visiting his physician to receive the results of a recent computed tomography scan of his abdomen. He is cognitively intact and still works 2 days a week. He is accompanied by his daughter Eleanor. She takes the doctor aside before the appointment and says, "Please do not tell my father any bad news. It would just kill him." If the physician were to agree, which ethical principles might this violate? a. Paternalism b. Autonomy c. Authenticity d. None of the above e. Answers a, b, and c B Lenore White is an 80-year-old woman who smokes two packs of cigarettes per day. She is hospitalized for pneumonia because she has presenting symptoms of cough and fever. On her second day of hospitalization, she asks the nurse to please wheel her outside so she can smoke a cigarette. The nurse feels uncomfortable agreeing to this and speaks to her clinical nurse manager. What two ethical principles are in conflict? a. Beneficence and community b. Nonmaleficence and justice c. Autonomy and justice d. Autonomy and nonmaleficence D

Ms. Greta Thornberg is an 88-year-old woman admitted to the hospital with a diagnosis of squamous cell carcinoma of the lung with metastases to liver. She has signed a POLST indicating that she would like no limitation on life-sustaining measures, including resuscitation, artificial feeding, antibiotics, and hydration. On the second day of her stay, she sustains a stroke, resulting in global aphasia and hemiparesis. As her clinician, in addition to instituting appropriate medical management, you contact her healthcare agent and: a. Inform her healthcare agent of the POLST and notify her that it cannot be changed. b. Inform her healthcare agent of the POLST and notify her that the change of condition requires that the POLST be reviewed. c. Ask her healthcare agent to locate her Last Will and Testament. d. Since she has a signed POLST, there is no reason to contact the healthcare agent. B A 75-year-old man with lung cancer metastatic to the bones is receiving hospice care in his home. His predominant symptom is nociceptive and neuropathic right chest wall pain caused by a fourth rib metastasis. In recent days he has experienced a dramatic increase in his pain, and hospice staff have titrated his pain regimen to gabapentin 900 mg three times daily, extended release morphine 100 mg three times daily, and immediate release morphine 30 mg every 2 hours as needed. The hospice nurse calls you to ask about next steps, and reports that he is still in severe pain but is now nonverbal, and his family is struggling to administer his medication orally because of his somnolence. The patient's family is exhausted. What is the best next step to assure the patient's comfort? a. Admit to an inpatient facility under the General Inpatient Hospice benefit. b. Discharge from hospice, admit to the hospital. c. Call 911. d. Instruct the family to give the immediate release morphine every 30 minutes instead of every 2 hours. A

An 85-year-old woman with congestive heart failure, end-stage chronic obstructive pulmonary disease, chronic kidney disease stage 4, and frailty is brought to your office for a routine appointment. She has preserved cognition and her last Mini-Mental State Examination was 26. Affect is normal, and she has no history of depression. She has a loving and supportive family with whom she lives. During the visit, she shares that her quality of life is no longer acceptable, and asks about options to hasten the end of her life. Which of the following means of hastening death is legal throughout the United States? a. Euthanasia b. Palliative sedation c. Voluntary stopping of eating and drinking d. Physician-assisted death C A 78-year-old woman with atherosclerotic cardiovascular disease (ASCVD), peripheral vascular disease, and a history of transient ischemic attacks s/p carotid endarterectomy is seen as part of an annual wellness visit. She is advised to create an advance directive but declines, saying "I don't know who to pick" for a healthcare agent. Which one of the following is a necessary characteristic of a healthcare agent? a. Geographic proximity to the patient's home b. Knows how the patient defines quality of life c. Is a member of the patient's immediate family d. Has medical training or experience B urinary incontinence involuntary urine leakage urgency

sudden need to void urgency incontinence sudden need to void followed by leakage frequency frequent urination hesitancy difficulty in initiating urine stream straining effort to initiate or maintain urine stream dribbling leakage or small amounts of urine after voiding nocturia waking during the night to void overactive bladder urgency, frequency, and nocturia

treatment for urinary incontinence Treat Comorbidity Comorbidities, such as sleep apnea and diabetes, must be managed before implementing other treatments for urinary incontinence. Current medications should be reviewed to identify those that might precipitate incontinence. Lifestyle Lifestyle interventions include weight loss, reducing consumption of caffeine and alcohol, decreasing fluid intake before bed, and smoking cessation. Behavioral Therapies Behavioral therapies include bladder training and pelvic muscle exercises; both are useful for urgency and stress incontinence. Bladder training includes frequent voiding (i.e., every 2 hours) along with visualization and muscle contractions to help control urgency. As training progresses, the time between voluntary voids is increased. The training process may take several weeks (Mazur-Bialy et al., 2020). Pelvic muscle exercises, or Kegels, help to strengthen the pelvic floor. Exercises may be done throughout the day, with a goal of three sets of 10- 12 per day. Exercises may begin to improve incontinence within a month. Prompted voiding may decrease incontinence episodes in cognitively impaired clients. The caregiver should prompt the client to report the need to void throughout the day and assist in toileting every 2-3 hours (Mazur- Bialy et al., 2020). Medications Pharmacologic therapy is not approved for stress incontinence but may be prescribed for the management of urgency incontinence or overactive bladder and includes: Antimuscarinic medications: oxybutynin (Ditropan), tolterodine (Detrol) · monitor for anticholinergic adverse effects · drugs interact with drugs that induce CYP2D · the American Geriatrics Society 2019 Beers Criteria recommends avoiding antimuscarinics in clients with dementia or cognitive impairment Beta-3 Agonist: mirabegron (Myrbetriq)

· interacts with drugs that induce CYP2D · potential adverse effect: increased BP Minimally Invasive Procedures Minimally invasive procedures may be considered for clients who have urgency incontinence that does not respond to behavioral interventions or medications. Referral to urology is appropriate for clients seeking minimally invasive procedures or surgery. Procedures for urgency incontinence include: · onabotulinumtox UTI's in community dwelling older adults For older adults who reside in the community, symptomatic UTIs are similar in presentation to younger adults and may include dysuria, frequency, urgency, and hematuria. Postmenopausal women may also complain of incontinence, nocturia, low back pain, and constipation Unlike with younger adults, treatment should not be initiated based solely on symptoms, as common symptoms may mimic other disease processes. A urine dipstick to evaluate for bacteriuria and pyuria is required. If nitrites and/or leukocytes are present, using symptomatic treatment until microbiology results are available to direct targeted antibiotic therapy can help reduce antibiotic resistance UTI's in LTC facilities Residents of long-term care facilities may not present with typical signs of UTIs, and they may be more likely to have chronic urinary symptoms such as frequency, nocturia, or incontinence. Change in mental status may be the most common symptom associated with UTI in long-term care. Other symptoms of a suspected UTI in this population include a change in urine character, fever, declining functional status, and hematuria. Evidence-based consensus criteria should be used to determine when to initiate treatment.

McGeer criteria Acute dysuria OR Fever >37.9 Celsius plus one of the following: · Urgency · Frequency · Suprapubic pain · Gross hematuria · Costovertebral angle tenderness · Urinary incontinence Loeb criteria Three of the following: · Fever >38 Celsius · New/increased burning, frequency, urgency

· New flank or suprapubic pain · Change in character of urine · New or worsening mental status changes Benign prostatic hyperplasia is a multifactorial disease process involving smooth muscle hyperplasia, prostate enlargement, and bladder dysfunction influenced by signals from the central nervous system. BPH can lead to lower urinary tract symptoms (LUTS) due to hyperplasia of prostate tissue which may anatomically narrow the urethra and obstruct the flow of urine from the bladder as seen below. Age is the most common risk factor for BPH. Benign Prostatic Hyperplasia Normal prostate -Urine -Prostate -Urethra Enlarged prostate -Urine -Enlarged prostate

-Compressed urethra Prostate cancer prostate cancer is the second most common form of cancer among men. Age is the most common risk factor. The prostate tends to increase in size in an aging man. The older a man is, the greater his chance of getting prostate cancer. Black men have higher rates of prostate cancer than men of other races. They are also twice as likely to die from the disease and tend to develop it at a younger age. Black men also tend to have a more severe type of prostate cancer than men of other races. Clients are often asymptomatic during the early stages of the disease. Later symptoms include lower urinary tract symptoms. The digital rectal examination (DRE) is an essential assessment for BPH and is used to assess prostate size, contour, and presence of abnormal nodules. The international prostate symptoms scale is a validated questionnaire that measures the severity of lower urinary tract symptoms (LUTS). A score of 7 or less indicates mild symptoms, 8 to 19 indicates moderate symptoms and 20 to 35 indicates severe symptoms. Although it indicates prostatic issues, it is not a diagnostic tool for BPH. Erectile Dysfunction Erectile dysfunction (ED) is a common problem; ED screening is an essential component of a routine health assessment. ED is a sensitive topic. A candid conversation about ED is more likely to occur when there is trust within the client-provider relationship. Due to the nature of ED and its impact on intimate relationships, a sexual partner may initiate the conversation. Regardless of who starts the discussion, it is important to discuss causes and treatment options

Risk factors · cardiovascular (hypertension, coronary artery disease, hyperlipidemia, peripheral vascular disease) · diabetes mellitus · depression · obesity · alcohol use · medication use (antihypertensives, antidepressants, antiandrogenic agents) · history of pelvic surgery/trauma/radiation · neurologic diseases · endocrinopathies (hyper/hypothyroidism, hypogonadism, corticosteroid use) Assessment History · International Index of Erectile Dysfunction (IIED) oComposed of 15 questions

oAddresses all domains of male sexual dysfunction · Sexual Health Inventory for Men oShort version (five questions) of IIED Physical Exam · Femoral and peripheral pulses for strength and bruit · Assessment for penile plaques · Hair growth patterns, gynecomastia, or small testes · Cremasteric reflex · Visual field defects may indicate pituitary tumors Diagnostic testing such as hemoglobin A1c, thyroid function studies, and lipid panel may reveal the underlying cause. All men with ED should have at least two morning serum total testosterone tests to identify testosterone deficiency. The cremasteric reflex is used to determine if the cause of the ED is neurological. Alzheimer’s disease, stroke, and certain medications can interfere with nerve signals Follow up: Follow-up visits 6-8 weeks after initiating medical treatment are recommended. Treatment failure for at least four sexual attempts is indicated before changing medications or treatment modality. Referrals to

urology or endocrinology are warranted for complicated cases or treatment failure. Menopause Menopause occurs when menstruation permanently ceases and is a significant milestone in the female life cycle. For most women, menopause occurs at an average age of 51 years. It is preceded by a transition state called perimenopause where hormonal changes start causing noticeable symptoms. The process can last over a decade and usually starts around age 40. Menopause has four stages: premature menopause, perimenopause, menopause, and postmenopause. Menopause is considered premature if it begins before the age of 40. Hot flashes and night sweats · Avoid triggers- spicy foods, hot drinks, alcohol, and caffeine · Maintain a cool environment, layer clothing · Increase exercise Vaginal dryness · Vaginal estrogen · Vaginal moisturizer · Lubricants during sex Mood changes

· Selective serotonin reuptake inhibitors (SSRIs) Osteoporosis · Calcium and vitamin D supplements · Bone density scans Hormone replacement therapy Nonhormone therapies provide sufficient relief for most women with mild symptoms Hormone replacement therapy (HRT) may be indicated for more severe symptoms and helps to prevent bone loss. There are two types of HRT: estrogen-only (ET) or estrogen plus progestin (EPT). EPT is indicated for women who have not had a hysterectomy to help prevent uterine cancer. HRT is delivered systemically (e.g., oral tablets, patches, injections) or locally (e. g., creams, vaginal rings); the lowest effective dose should be prescribed for the shortest amount of time to minimize risks. Risks include stroke, blood clots, and breast cancer. Each woman should be assessed individually, and the benefits should outweigh the risks. Selective estrogen receptor modulators (SERMs) block or activate estrogen receptors in certain areas of the body and is an alternative treatment for women with a history of breast cancer or those with concerns about using HRT Postmenopausal bleeding Postmenopausal bleeding is genital tract bleeding in a woman who is not on HRT or non-cyclical bleeding in a menopausal woman on HRT. The most common cause of postmenopausal bleeding is benign vaginal atrophy. Atrophy is easily recognized on physical exam by the presence of a thin, pale vaginal epithelium along with narrowing of the introitus. Subjectively,

the client will complain of dyspareunia and possibly post-coital bleeding. Other conditions cause postmenopausal bleeding. Vaginal atrophy: local or systemic estrogen Endometrial atrophy: short cause of systemic estrogen Endometrial polyps: surgical removal Uterine fibroids: surgical removal Endometrial hyperplasia: medical management to prevent the progression to endometrial cancer including systemic progesterone's or hormonal intrauterine device (IUD) to thin uterine lining. Cancers (endometrial, ovarian, cervical, vaginal): total hysterectomy, radiation. Genitourinary syndrome of menopause (GSM) is a new term to describe vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy due to estrogen deficiency and is characterized by a broad spectrum of signs and symptoms Cognitive domains Complex attention: easily distracted, difficulty with mental calculations and multitasking Executive function: unable to complete complex projects or solve problems, difficulty with instrumental activities of daily livings and making decisions Learning and memory: frequent reminders needed, recent memory impaired Language: difficulties with expressive or receptive language, word-finding difficulty Perceptual motor: difficulty with navigating familiar environments or using complex tools (carpentry, sewing) Social cognition: changes in behavior or attitude, declining ability to read and respond to social cues.

Delirium Acute, fluctuating syndrome involving disorganized thinking, altered attention and awareness, and variable levels of consciousness. More common in hospitalized adults or residents in LTC facilities. Symptoms are often worse later in the day, and sleep-wake disturbances increase the incidence of symptoms. Subtypes: Ø Hyperactive

• Heightened arousal
• Restless
• Agitation
• Hallucinations Ø Hypoactive
• Lethargy
• Reduced motor activity
• Incoherent speech Ø Mixed
• Combination of hypoactive and hyperactive symptoms Cognitive assessments Ø Mini-cog: three-item recall test and a scored clock-drawing test that can be effectively used with minimal training. Assessment helps determine the need for a full-diagnostic assessment. Ø Geriatric depression scale: often used to initially assess depression in older adults. This brief survey instrument is used in conjunction with other tools for full cognitive assessments. Ø Montreal cognitive assessment (MoCA): evaluates eight cognitive domains. Ø Saint Louis University Mental Status: evaluates clients orientation, executive function, memory, and attention. Preliminary tool that is used to determine a full-diagnostic assessment is warranted.

Dementia/AD Most cases are associated with degenerative or vascular causes. However, other causes are possible and may include infections, inflammatory processes, neoplasms, toxic influences, metabolic disorders, and trauma. Diagnostic testing: Labs, CT to identify if there are any brain tumors or structural issues, MRI to identify atrophy, vascular lesions, neurofibrillary tangles, amyloid plaques, amyloid PET can make an earlier and more accurate diagnosis of Alzheimer dementia. Treatment: currently no treatment but treatment can address other biometric factors and support that can be improve the lives of the individuals. Follow up: regular follow up recommended to assess the clients condition and cognitive and noncognitive symptoms. Pharmacotherapy: N-methyl-D-aspartate (NMDA) or cholinesterase inhibitors to treat symptoms related to memory and thinking. Memantine is used for clients with moderate-severe dementia. Blocks the effects of abnormal glutamate release, an excitatory neurotransmitter. Donepezil, rivastigmine, or galantamine may be used in clients with mild-severe dementia associated AD. These drugs act by inhibiting acetylcholinesterase, thus improving cholinergic function, and increasing the circulation of acetylcholine. Aducanumab has been used with clients with mild dementia in clinical trials. This drugs act by binding to and reducing amyloid-beta plaque in the brain. Non-pharmacological interventions: physical activity, consistent surroundings and routines, diet, memory aids, cognitive stimulation, cognitive behavioral therapy, support groups. Referrals: caregiver support groups, medical specialties, and community- based organizations for services such as adult daycare, counseling, and caregiver training. Parkinson's disease Motor symptoms: Cardinal features: tremor, bradykinesia, rigidity, postural instability

Motor symptoms: Craniofacial: Hypomimia (masked facial expression), decreased spontaneous eye blink, speech impairment (dysarthria, hypophonia), and dysphagia. Motor symptoms: visual: blurred vision, impairment upward gaze and convergence, eyelid opening apraxia. Motor symptoms: musculoskeletal: dystonia, myoclonus, stooped posture, kyphosis. Motor symptoms: Gait: shuffling, freezing. Non-motor symptoms: cognitive dysfunction and dementia, psychosis and hallucinations, mood disorders, sleep disturbances, fatigue, autonomic dysfunction, olfactory dysfunction, GI dysfunction, pain and sensory disturbances, dermatologic issues. Treatment: A tremor that does not impact ADLs does not warrant medications. For motor symptoms that affect function, Levodopa is first line treatment. Although clients may have side effects of dyskinesia during the first five years of treatment. Dopamine agonists may also be prescribed, but are more likely to cause impulse control disorders, daytime fatigue, and hallucinations. MOA-B inhibitors also cause dyskinesia and insomnia is common. Dizziness Risk factors of dizziness: anxiety, depression, impaired balance, past MI, postural hypotension, polypharmacy, impaired hearing. Possible medications causing dizziness: antihypertensives, benzodiazepines, hypnotics, anxiolytics, antiepileptics. Major depressive disorder Clinical presentation: depressed mood and a loss of interest or pleasure. May also present with physical symptoms: fatigue, inattention, poor appetite, decreased libido, psychomotor retardation, or agitation. Often report difficulty sleeping, lack of motivation, or trouble completing tasks.

Stages: DSM-5 classifies MDD by severity, mild, moderate, or severe, with or without psychotic features. Mild: the intensity of symptoms is manageable with minimal impairment in functioning. There are a few symptoms beyond those required by diagnosis. Moderate: The number of symptoms, intensity, or impairment in functioning is between mild and severe. Severe: The intensity of symptoms is unmanageable and distressing. Symptoms interfere with functioning. The number of symptoms is beyond what is required for diagnosis. When diagnosing a depressive disorder, it is necessary to rule out medical and other mental health conditions that present with symptoms of depression. Baseline laboratory values are used to rule out a medical diagnosis or other condition and include a comprehensive metabolic panel (CMP), complete blood count (CBC), vitamin B12 level, vitamin D level, thyroid function tests, and/or a toxicology screen. Anxiety Clinical presentation of anxiety in older adults may differ from what is seen in younger clients. Older adults often have a weaker autonomic nervous system response to fear, which may decrease the intensity of the physical symptoms of anxiety. Anxiety is often comorbid with major depression as well as medical conditions such as chronic pulmonary obstructive disease (COPD), asthma, and diabetes. Anxiety can impact disease management, increase complications, and lower treatment adherence. When diagnosing an anxiety disorder, it is necessary to rule out medical and other mental health conditions that present with symptoms of depression. Baseline laboratory values are used to rule out a medical diagnosis or other condition and include a comprehensive metabolic panel (CMP), thyroid function tests, and/or a toxicology screen.

insomnia Inability to sleep can be transient or chronic; however, a diagnosis of insomnia requires complaints occurring at least 3 nights a week for 3 months or more. Persistent insomnia is associated with decreased concentration, attention, and quality of life; increased irritability; and long- term effects such as the increased risk of major depressive disorder, hypertension, and myocardial infarction Hypersomnolence disorder classify excessive quantity of sleep, difficulty awakening or staying awake, and difficulty awakening. Clients with hypersomnolence disorder may sleep longer than 9 hours per night but the sleep does not feel restful or restorative. Daytime naps are common, as are unintentional sleep episodes while reading or watching TV. Confusion and memory impairment, known as sleep inertia, are common upon awakening. Narcolepsy defined as recurrent periods of napping or falling asleep without warning several times per day. Narcolepsy may be accompanied by cataplexy, or the bilateral loss of muscle tone triggered by emotions, particularly laughter or excitement. Because clients with narcolepsy may also present with hypocretin (orexin) deficiency and abnormal rapid eye movement (REM) sleep latency, cerebrospinal fluid analysis, nocturnal polysomnography (PSG), and a multiple sleep latency test (MSLT) should be completed before diagnosis. Only 15-30% of people with narcolepsy are diagnosed or treated. Almost half present for diagnosis after age 40. Breathing related sleep disorders include obstructive sleep apnea (OSA), central sleep apnea (CSA), and sleep-related hypoventilation. OSA is the most common breathing-related sleep disorder, caused by upper airway obstruction during sleep, which leads to periods of apnea and heavy snoring. OSA is commonly diagnosed in adults aged 40-60. Risk factors include obesity and family history. Clients with breathing-related sleep disorders typically present with

excessive daytime sleepiness. They may also have trouble concentrating during the day, mood changes, awakening with a dry mouth or sore throat, morning headaches, or decreased libido. Partners may endorse snoring, apneic periods, and abrupt awakenings accompanied by gasping or choking. Circadian rhythm sleep-wake disorders physical and behavioral changes related to responses to light and dark that may be transient or chronic. Circadian rhythm sleep-wake disorder occurs when this endogenous, 24-hour cycle is disrupted, causing excessive daytime sleepiness, insomnia, or both. Disruptions in sleep schedule due to illness or shift work may cause transient disorder, while non-24-hour sleep-wake disorder may cause chronic disturbances in sleep. This is a common disorder of clients with blindness due to their inability to see light. Parasomnias are abnormal behavioral, physiological, or experiential events that occur during sleep. Parasomnias may be diagnosed when the episodes cause clinically significant distress or impairment. · Nightmare disorder involves repeated, vivid, dysphoric dreams which clients clearly remember. Clients are alert and oriented upon awakening. Typical nightmare themes relate to threats to the client's survival or security. · REM sleep behavior disorder involves arousal during REM sleep with accompanying vocalizations and complex motor behaviors, such as kicking, running, or punching. REM sleep disorders are often a precursor of Parkinson's disease or neurocognitive disorder with Lewy bodies. · Restless legs syndrome (RLS) involves urges to move the legs to reduce unpleasant sensations, such as itching or tingling, during periods of rest. · Trauma-associated sleep disorder (TASD) is a parasomnia with characteristics of REM sleep behavior disorder and post-traumatic stress disorder. TASD can stem from traumatic experiences such as war

Palliative and Hospice care Differences between palliative and hospice care services Palliative care is specialized healthcare for clients with serious illnesses. Holistic in nature, palliative care is provided by a team of physicians, advanced practice registered nurses, physician assistants, nurses, social workers, and chaplains that focus on pain and symptom management. Hospice is described as care and services for clients with an incurable or serious illness who have 6 months or less to live. The goal of hospice care is to minimize pain and suffering and prepare clients and families for the end of the life. SPIKES Protocol An effective strategy for communicating sensitive information about advance care planning while focusing on client emotions. S: setting P: perception- determine what the patient knows already I: invitation: clarify information preferences K: Knowledge: give the information E: Empathy: respond to the emotion S: Summary: next steps and follow up plan death and dying stages Kubler-ross stages of dying. Denial Anger Bargaining Depression Acceptance

Normal grief a natural response to a painful event or loss. Common reactions include sadness, guilt, loneliness, crying, changes in sleep, lack of energy, appetite changes, withdrawal from normal social activities, and difficulty concentrating. anticipatory grief a response to an expected loss, occurring before the actual death or loss. May affect both the client and family. Can lead to both intimacy or withdrawal and separation. disenfranchised grief occurs when a loss cannot be socially acknowledged, mourned, or supported. It often occurs in marginalized populations. It happens when there is no recognition of the loss, the griever, or the relationship between the loss and the mourner. Often minimized or not understood by others, which makes it a difficult process to work through. prolonged grief occurs when grief symptoms like sadness, anger, bitterness, and guilt, are disabling, limiting day-to-day functioning. Prolonged grief may involve difficulty accepting the reality of a loss, self-destructive behavior, or suicidal thoughts. It is distinct from major depressive disorder and posttraumatic stress disorder and requires specialized therapy Bereavement

The normal period of grief and mourning after a death. The CMS specify that bereavement services must be offered to families for up to one year after the death of the client. Beneficence Doing good or causing good to be done; kindly action autonomy upheld when the nurse accepts the client as a unique person who has the innate right to have their own opinions, perspectives, values and beliefs. Nurses encourage patients to make their own decision without any judgments or coercion from the nurse. The patient has the right to reject or accept all treatments. nonmaleficense an ethical principle stating the duty to not inflict harm justice fairness; rightfulness rules of fourths and aging Changes often attributed to normal aging: about one fourth is due to disease, one fourth to disuse, one fourth to misuse, and only one fourth to physiologic aging. elder abuse

Ø Psychological abuse

• Infliction of pain or distress via verbal or nonverbal means
• Examples: threats, isolation, humiliation Ø Sexual abuse
• Non-consensual sexual contact or interaction of any kind with a vulnerable elder
• Examples: forced sexual activity, suggestive talk, nonconsenting touch Ø Financial exploitation
• Illegal or improper use of a vulnerable elder's property, funds, or assets
• Examples: theft, coercion to deprive assets Ø Neglect
• Refusal or failure of those responsible, to provide life necessities for a vulnerable elder
• Can be self-neglect
• Examples: failure to provide food, medications, medical care, hygiene Ø Abandonment
• Desertion of a vulnerable elder by the person who assumed responsibility for that elder
• Examples: hitting, force-feeding, use of unordered restraints Ø Physical abuse
• Physical force resulting in physical injury, pain, or impairment to a vulnerable
• Examples: hitting, force-feeding, use of unordered restraints Management of abuse: assessing the functional and cognitive status of the client provides a baseline for identifying the degree of dependence and vulnerability. Medicare Part A For most clients, there is no monthly premium.