Learning Objectives
By the end of this section, you will be able to:
- Outline how care is customized for older adults
- Understand the role of the psychiatric-mental health nurse in providing care for older adults within a collaborative approach to treatment
Caring for older adults can be very complex because there are many factors to consider and manage. It is also very rewarding and is different than caring for any other age group. Older adults have so much to share about their lives and experiences. They have problems and issues just like any other person, but so much can be learned from the ways that they have overcome hardships in their lives. Frequently, caring for an older adult includes caring for children or other family members as well. The care must be customized to include caregivers in that plan. Nursing interventions should be specifically tailored to this population.
Customized Care for the Older Adult
Just like younger adults, each older adult is different. For example, one person who is eighty years old may be very functional and even still working. Yet another eighty-year-old may be functionally dependent and ill. Each individual person deserves customized care based on their level of health and function. Some older adults require direct involvement of a family member for personal care or supervision whereas others may not require family involvement. Communication is the key to discovering what is important to each person and the others potentially involved in their care.
Therapeutic Communication
In all nursing care, the therapeutic relationship with the client is essential. This is especially so in psychiatric care, where the therapeutic relationship is considered to be the foundation of client care and healing. Nurses engage with clients in caring, supportive, nonjudgmental interactions within a safe environment, often during a stressful period for the client. Being present and actively listening is the most valuable tool that the nurse has. For older adults with sensory or cognitive impairment, the environment is very important for privacy and quiet with few distractions.
Clinical Safety and Procedures (QSEN)
Using Effective Communication Skills Promotes Quality Mental Health Care
Tips for effective communication from the WHO mhGAP Intervention Guide include the following:
- Create an environment that facilitates open communication.
- Involve the person.
- Start by listening.
- Be friendly, respectful, and nonjudgmental.
- Use good verbal communication skills.
- Respond with sensitivity when people disclose traumatic experiences (i.e., sexual assault, violence, or self-harm).
(WHO, 2019)
Comprehensive Assessment
To develop a practical and client-centered treatment plan, older persons with unexplained or ambiguous symptoms will benefit from a comprehensive geriatric assessment (CGA), which assesses older adults across various domains of health. The CGA assesses the following major areas: functional status, gait speed, cognition, mood, nutritional status, comorbidity, polypharmacy, geriatric syndromes, social support, financial concerns, environmental suitability, and advance care planning. The CGA helps to prioritize treatments that are in line with client goals by attempting to understand disease in the context of function and adaptation. It may also spot opportunities to improve health status by gaining access to community resources or by stopping treatments that are out of line with client goals. The CGA utilizes evidence-based evaluation instruments in a variety of areas, including mood and anxiety, in addition to an interdisciplinary approach.
Outcomes of Care
An outcome is a client behavior that can be measured in response to an intervention used by a nurse. The Outcomes Identification Standard of Practice by the American Nurses Association states, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.” The registered nurse:
- engages with the health-care consumer, interprofessional team, and others to identify expected outcomes
- collaborates with the health-care consumer to define expected outcomes integrating the health-care consumer’s culture, values, and ethical considerations
- formulates expected outcomes derived from assessments and diagnoses
- integrates evidence and best practices to identify expected outcomes
- develops expected outcomes that facilitate coordination of care
- identifies a time frame for the attainment of expected outcomes
- documents expected outcomes as measurable goals
- identifies the actual outcomes in relation to expected outcomes, safety, and quality standards
- modifies expected outcomes based on the evaluation of the status of the health-care consumer and situation
After implementing nursing interventions, the nurse evaluates if the outcomes were met in the time frame indicated for that client. Outcome identification includes setting short-term and long-term goals and then creating specific expected outcome statements for each nursing diagnosis. Outcome statements are always client-centered. They should be developed collaboratively with the client and individualized to meet the client’s unique needs, values, and cultural beliefs. They should start with the phrase “The client will . . . ” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the client finds worth achieving.
Outcome statements should contain five components easily remembered using the “SMART” mnemonic (Figure 24.7).
Nurses’ Role in Collaborative Care
Nurses are collaborating with others in client care on a regular basis. All nursing interactions with another team member involved in the care of a client is a collaboration. For example, when a client is struggling with their pain, the nurse may discuss and collaborate with the provider about the medications or a change in the treatment plan. They may also collaborate with the client’s social worker or case manager about increasing caregiver time or any number of possible social supports that the client may need or be eligible for. The nurse also may collaborate with the client’s family if they are directly involved in the care. Psychiatric-mental health nurses participate in this care constantly, whether it is formal (i.e., the treatment team) or informal (i.e., discussing client care during a family visit).
Nursing Interventions
Implementation of interventions requires the nurse to use critical thinking and clinical judgment. After developing the initial plan of care, the nurse should continually assess the client to detect any changes in condition requiring modification of the plan. Should a modification be needed, the nurse collaborates with the team to make those modifications. The need for continual client reassessment underscores the dynamic nature of the nursing process and is crucial to providing safe care.
During the implementation phase of the nursing process, the nurse prioritizes planned interventions, assesses client safety while implementing interventions, delegates interventions as appropriate, and documents interventions performed. Prioritizing implementation of interventions follows a similar method to prioritizing nursing diagnoses. Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation help to establish top-priority interventions. When possible, use the least restrictive interventions possible.
It is essential to consider client safety when implementing interventions. At times, clients may experience a change in condition that makes a planned nursing intervention or provider prescription no longer safe to implement. For example, an established nursing care plan for a client states, “The nurse will ambulate the client 100 feet three times daily.” During assessment this morning, however, the client reports feeling dizzy, and their blood pressure is 90/60 mmHg. Using critical thinking and clinical judgment, the nurse decides not to implement the planned intervention of ambulating the client and notifies the provider of suspected side effects of the client’s antidepressant medication. This decision, supporting assessment findings, and notification of the provider should be documented in the client’s chart and also communicated during the shift handoff report (Table 24.8).
| Subcategories: Implementation Standard of Care | Sample Nursing Interventions |
|---|---|
| Coordination of care |
|
| Health teaching and health promotion |
|
| Pharmacological, biological, and integrative therapies |
|
| Milieu therapy |
|
| Therapeutic relationship and counseling |
|
Nursing Competency
APNA’s Pharmacological, Biological, and Integrative Therapies Competencies states that a psychiatric-mental health registered nurse (PMH-RN) applies clinical skills with knowledge of pharmacological, biological, and complementary interventions to improve and maintain clients’ health (APNA, 2022). As a result, the PMH-RN applies current research findings to guide nursing actions related to pharmacology, other biological therapies, and integrative therapies. The nurse also assesses the health-care consumer’s response to biological interventions based on current knowledge of pharmacological agent’s intended actions, interactive effects, potential untoward effects, and therapeutic doses. Another competency includes medication management to support health-care consumers in managing their own medications and adhering to a prescribed regimen. The nurse provides health teaching about mechanism of action, intended effects, potential adverse effects of a proposed prescription, ways to cope with transitional side effects, and other treatment options, including the selection of a no-treatment option. In terms of the team, the nurse communicates observations about the health-care consumer’s response to biological interventions to other health clinicians.
Advocacy and Teaching
ANA’s Health Teaching and Health Promotion Competencies include nursing education. Nurses should offer opportunities for the health-care consumer to identify needed health promotion, disease prevention, and self-management topics, such as healthy lifestyles; self-care and risk management; and coping, adaptability, and resiliency. Nurses should make sure to use health promotion and health teaching methods, including technology, in collaboration with the health-care consumer’s values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status. They should also use feedback from the health-care consumer and other assessments to determine the effectiveness of the employed strategies. Nurses also provide anticipatory guidance to health-care consumers to promote health and prevent or reduce risk.
Family Support and Transitional Care
Any move of a client from the hospital to skilled nursing, skilled nursing to home, inpatient mental health facility to outpatient mental health or psychiatrist is considered to be a transition of care. There are many possible transitions, and they can be difficult for the client and the family. This is also a time that has a high possibility for errors in communication and in medications. These errors have also been shown to be linked to adverse effects, low satisfaction, and high rehospitalization rates. The nurse can be pivotal in many of these issues by providing a detailed and carefully reviewed discharge and handoff to the client and the family. Follow-up calls to the client and families are also helpful in being able to review the handoff education and medications.