• Resume highest level of functioning possible

• Express feelings

• Participate in activities of daily living (ADLs)

• Participate in social interactions

• Consume adequate dietary intake for weight and height

• Maintain usual weight

• Maintain adequate fluid intake with no signs of dehydration

• Maintain clean personal and home environment

• Elderly clients who have failure to thrive (FTT) should be evaluated by review of their ADLs, cognitive function, and mood; a comprehensive history and physical examination; selected laboratory studies and screening for alcohol and substance abuse. Adult failure to thrive requires comprehensive assessment since it may include impaired function, malnutrition, depression, and cognitive impairment; psychosocial factors such as a series of losses contribute to the development of failure to thrive, and supportive treatment should be initiated to prevent deterioration (Rocchiccioli & Sanford, 2009). EB: Older adults with mental status and behavioral changes must be evaluated for delirium, which is often underdiagnosed or misdiagnosed as depression or dementia (Mittal et al, 2011). Delirium superimposed on dementia may resolve at a slower rate (Boettger, Passik, & Breitbart, 2011). EBN: Alcoholism is frequently missed in older adults because they drink in private (Rocchiccioli & Sanford, 2009).

• Assess for depression with a geriatric depression scale. Be alert for depression in clients newly admitted to nursing homes. EBN: Clients admitted to nursing homes may have lack of perceived social support and signs of depression (Rocchiccioli & Sanford, 2009). EB: Depression is the most common silent killer in geriatrics (Chakraborty, 2009).

• Screen for depression in persons with adult macular degeneration (AMD) and low vision or vision loss. EB: Rates of depression in AMD are substantially greater than those found in the general population of older adults (Casten & Rovner, 2008).

 Carefully assess for elder abuse and refer for treatment. EB: Abuse of older people is a serious and growing social problem; victims of severe abuse were more likely to be female, abuse alcohol or drugs, or have a neurological or mental health disorder (Friedman et al, 2011).

• Encourage the client to make decisions independently; offer choices. EBN: Loss of independence, decision- making opportunities, and loss of function may lead to feelings of hopelessness (Rocchiccioli & Sanford, 2009).

• Instill hope; assist client to manage chronic conditions through education and social support. EBN: Nurses may instill hope in individuals with chronic illness by establishing therapeutic relationships with the client, empowering them to adapt to living as well as possible with their condition, and by reinforcing positive social supports (Milne, Moyle, & Cooke, 2009).

• Provide music for clients with dementia, pain, acute confusion, and functional deficits. EBN: Music is a safe, inexpensive, and easy-to-use intervention that nurses can implement independently to help older adults cope (McCaffrey, 2008).

 Consider the use of light therapy. EBN: Bright light therapy is effective for the treatment of seasonal affective disorder (Holland, 2009).

 Provide opportunities for visitation from animals. EBN: Animal-assisted therapy may be utilized for reality orientation, stress and anxiety reduction, and emotional and social support (DeCourcey, Russell, & Keister, 2010).

• Encourage clients to reminisce and share and compile life histories. EBN: Reflecting on the past and sharing memories with others is an excellent way of facilitating communication. Be sensitive that some people do not like to look back but prefer to enjoy the present and look forward (Swann, 2008)EB: Group reminiscence was found to enhance memory performance and increase well-being (Haslam et al, 2010).

• Complete a spiritual assessment and support the client’s spirituality; encourage clients to connect with their preferred faith community, and to pray if they wish. EB: Spiritual well-being positively impacts physical and emotional health (Rosmarin, Wachholtz, & Ai, 2011). Clients with dementia have spiritual needs (Dakin, 2009). Refer to care plan for Readiness for enhanced Spiritual Well-Being for additional interventions.

• Evaluate the social support system and help the client to identify ways they might increase social support. EBN: Clients with COPD identified the importance of positive relationships with their health care provider, family and friends, and relationship with God in maintaining hope (Milne, Moyle, & Cooke, 2009).

• Encourage older adult clients to take part in activities and social relationships according to their capacity and wishes. EBN: The specific behaviors that were found to ameliorate loneliness included utilizing friends and family as an emotional resource, engaging in eating and drinking rituals as a means of maintaining social contacts, and spending time constructively by reading and gardening (Pettigrew & Roberts, 2008).

• Help clients identify and practice activities that promote usefulness. EB: Older adults with persistently low perceived usefulness or feelings of usefulness may be a vulnerable group with increased risk for poor health outcomes in later life (Gruenewald et al, 2009).

• Provide physical touch or massage for clients. Touch the client’s hand or arm when speaking with him or her; offer hugs with permission. EB: Beneficial effects of massage include improved emotional health and a better perception of health (Munk & Zanjani, 2010). EBN: Ten-minute hand massages were found to reduce aggression and agitation in nursing home residents with dementia (Hicks-Moore & Robinson, 2008).

 Assess possible causes for adult FTT and treat or alleviate any underlying problems such as dysphagia, malnutrition, dehydration, depression, infection, diarrhea, renal failure, polypharmacy, sensory impairments, and illnesses caused by physical and cognitive changes. EBN: Cancer, heart failure, diabetes, chronic lung disease, dementia, depression, and sensory deficits are commonly associated with adult failure to thrive; failure to thrive is multifactorial, and necessitates a comprehensive assessment (Rocchiccioli & Sanford, 2009). EB: Older adults should routinely undergo medication review to decrease the inappropriate use of medications (Serqi et al, 2011).

• Assess for signs of fatigue and mental status changes that may indicate an infection is present. EB: Delirium is often missed in older adults and may be misdiagnosed as depression or dementia; early detection may decrease morbidity and mortality (Mittal et al, 2011).

• Monitor weight loss, food intake (leaving 25% or more of food uneaten at most meals), psychiatric/mood diagnoses, and decreased ability to participate in ADLs. CEB: The previous criteria are significant predictors of protein-calorie malnutrition (Higgins & Daly, 2005). EB: Monitoring weight is the simplest way to assess for protein-calorie malnutrition (Labossiere & Bernard, 2008).

• Assess for signs of dehydration; the Dehydration Risk Appraisal Checklist is a potential tool for determining this risk in nursing home residents (Mentes & Wang, 2010). EBN: Dehydration is the most common fluid and electrolyte imbalance in older adults; a higher score on the 17-item Dehydration Risk Appraisal Checklist may be used to prompt staff to monitor fluid intake and drinking behaviors in order to prevent dehydration (Mentes & Wang, 2010).

• Play soothing music during mealtimes to increase the amount of food eaten and promote decreased agitation. EB: Soothing music was associated with an improvement in nutritional intake for older adults with dementia in a hospital setting (Wong et al, 2008) and with a decrease in agitation in older adults with dementia in a long-term care facility (Chang et al, 2010).

• Decrease noise and increase lighting in the dining area. EBN: Residents eating in less supportive eating environments experience more eating disability (Slaughter et al, 2011).

• Serve “family-style” meals. EB: Creative dining options with eye-appealing and familiar menu options may decrease the risk of unintended weight loss; staff’s social interaction with residents may result in increased food intake (Dorner, Friedrich, & Posthauer, 2010).

 Refer to a dietitian for individualized nutrition therapy; include the older adult in food choice decisions. EB: A therapeutic diet that limits food choices and seasonings may lead to decreased food and fluid consumption (Dorner, Friedrich, & Posthauer, 2010).Weight loss is often unrecognized and is associated with increased morbidity and mortality (Chapman, 2011).

• Refer to care plan Readiness for enhanced Nutrition for additional interventions.

• Assess how often the frail older adult goes outdoors; encourage outside activities. EB: Experiencing the natural world may improve well-being and provide a sense of normalcy (Duggan et al, 2008).

• Provide creative opportunities for interaction with the natural environment. EBN: Indoor gardening has the potential to improve life satisfaction, promote social interaction, and decrease the perception of loneliness according to a small study of older adults living in nursing homes (Tse, 2010).

• Assess grip strength periodically and monitor for a decline in strength. EB: Higher grip strength is associated with lower risk of frailty; a decline in grip strength predicts a variety of adverse health outcomes (Xue et al, 2011).

• Assess and monitor physical function in terms of the client’s ability to complete with tools such as the Katz Index or Lawton Scale. CEB: The Katz ADL is the most appropriate instrument to assess functional status (Wallace & Shelky, 2007).

• Assess frailty with a tool such as the Edmonton Frail Scale. EB: The prevalence of frailty increases with age and is associated with adverse health outcomes; physical activity interventions may decrease frailty (Clegg, 2011).

• Provide strength and resistance training. EB: Participation in resistance exercise training slows the age-related loss of muscle and bone mass and strength; older adults can substantially increase strength and may increase endurance through resistance exercise training. High intensity resistance training is an effective treatment for clinical depression (Chodzko-Zajko et al, 2009).

• Promote participation in an exercise based balance program. EB: Participation in programs to improve balance may lead to an improvement in cognition and physical function, according to a pilot study (Shubert et al, 2010).

• Implement dance therapy. Exercise slows the progression of cognitive symptoms. EB: Dance as an exercise also increases self-esteem and social involvement (Purshouse & Mukaetova-Ladinska, 2009).

 Refer for possible pharmacological intervention. EB: For clients with unexpected weight loss who have no obvious underlying factors, appetite stimulants may be carefully considered on an individual basis (Fox et al, 2009).

• Refer to care plans for Imbalanced Nutrition: less than body requirements, Hopelessness, Spiritual Distress, Readiness for enhanced Spiritual Well-Being, Social Isolation, Chronic Sorrow, Chronic low Self-Esteem.

Multicultural:

Home Care:

Client/Family Teaching and Discharge Planning:

• Remain free of falls

• Change environment to minimize the incidence of falls

• Explain methods to prevent injury

:

• Safety guidelines. Complete a fall-risk assessment for older adults in acute care using a valid and reliable tool such as the Hendrich II model. Recognize that risk factors for falling include recent history of falls, fear of falling, confusion, depression, altered elimination patterns, cardiovascular/respiratory disease impairing perfusion or oxygenation, postural hypotension, dizziness or vertigo, primary cancer diagnosis, and altered mobility (Gray-Miceli, 2008). The Hendrich II Fall Risk Model is quick to administer and provides a determination of risk for falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications increasing risk (Hendrich, 2006). This tool screens for primary prevention of falls and is integral in a post-fall assessment for the secondary prevention of falls (Gray-Miceli, 2007).

• Screen all clients for balance and mobility skills (supine to sit, sitting supported and unsupported, sit to stand, standing, walking and turning around, transferring, stooping to floor and recovering, and sitting down). Use tools such as the Balance Scale by Tinetti or the Get Up and Go Scale. It is helpful to determine the client’s functional abilities and then plan for ways to improve problem areas or determine methods to ensure safety (Gray-Miceli, 2008).

• Recognize that when people attend to another task while walking, such as carrying a cup of water, clothing, or supplies, they are more likely to fall. CEB: Those who slow down when given a carrying task are at a higher risk for subsequent falls (Lundin-Olsson, Nysberg, & Gustafson, 1998).

• Carefully assist a mostly immobile client up. Be sure to lock the bed and wheelchair and have sufficient personnel to protect the client from falls. When rising from a lying position, have the client change positions slowly, dangle legs, and stand next to the bed prior to walking to prevent orthostatic hypotension.

• Use a “high-risk fall” armband/bracelet and fall risk room sign to alert staff for increased vigilance and mobility assistance. These steps alert the nursing staff of the increased risk of falls (Gray-Miceli & Quigley, 2011).

 Evaluate the client’s medications to determine whether medications increase the risk of falling; consult with physician regarding the client’s need for medication if appropriate. Polypharmacy, or taking more than four medications, has been associated with increased falls. Medications such as benzodiazepines, antidepressants, neuroleptics, sedatives and hypnotics, antiarrhythmics, and diuretics increase risk for falls (Gray-Miceli & Quigley, 2011). EB: Short- to intermediate-acting benzodiazepine and tricyclic antidepressants may produce ataxia, impaired psychomotor function, syncope, and additional falls (Fick et al, 2003). Side effects of these medications include drowsiness, confusion, loss of balance, orthostatic hypotension (Gray-Miceli & Quigley, 2011).

• Orient the client to environment. Place the call light within reach and show how to call for assistance; answer call light promptly.

• Use one quarter- to one half-length side rails only, and maintain bed in a low position. Ensure that wheels are locked on bed and commode. Keep dim light in room at night. CEB: Use of full side rails can result in the client climbing over the rails, leading with the head, and sustaining a head injury. Side rails with widely spaced vertical bars and side rails not situated flush with the mattress have been associated with asphyxiation deaths because of rail and in bed entrapment and should not be used (Capezuti et al, 2002).

• Routinely assist the client with toileting on his or her own schedule. Always take the client to bathroom on awakening and before bedtime. Keep the path to the bathroom clear, label the bathroom, and leave the door open. EBN: A study found that falls were most commonly associated with toileting, especially falling on the way from bed or chair to the bathroom (Tzeng, 2010).

 Avoid use of restraints if at all possible. Obtain a physician’s order if restraints are deemed necessary, and use the least restrictive device. The use of restraints has been associated with serious injuries including rhabdomyolysis, brachial plexus injury, neuropathy, and dysrhythmias, as well as strangulation, asphyxiation, traumatic brain injuries, and all the consequences of immobility (Evans & Cotter, 2008). CEB & EB: A study demonstrated that there was no increase in falls or injuries in a group of clients who were not restrained, versus a similar group that was restrained in a nursing home (Capezuti et al, 1999, 2002). A study in two acute care hospitals demonstrated that when restraints were not used, there was no increase in client falls, injuries, or therapy disruptions (Mion et al, 2001). EBN: A large study of hospitalized clients demonstrated that use of restraints was associated with an increase in the rate of falling of two or more times, compared with those who did not receive restraints (Titler et al, 2011).

• In place of restraints, use the following:

 Well-staffed and educated nursing personnel with frequent client contact with careful consideration during shift changes

 Nursing units designed to care for clients with cognitive or functional impairments

 Nonskid footwear, sneakers preferable

 Adequate lighting, night-light in bathroom

 Toilet frequently

 Frequently assess need for invasive devices, tubes, IVs

 Hide tubes with bandages to prevent pulling of tubes

 Consider alternative IV placement site to prevent pulling out IV

 Alarm systems with ankle, above-the-knee, or wrist sensors

 Bed or wheelchair alarms

 Wedge cushions on chairs to prevent slipping

 Increased observation of the client

 Locked doors to unit

 Low or very low height beds

 Border-defining pillow/mattress to remind the client to stay in bed

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