Evidence-Based Geriatric Nursing FU B O L L Protocols for Best Practice M T O E Z R ’ • FOURTH EDITION M • C E Z A A Marie Boltz, PhD, RN, APRN-BC • Elizabeth Capezuti, PhD, RN, FAAN • R W P E Terry Fulmer, PhD, RN, FAAN • DeAnne Zwicker, DrNP, APRN-BC • EDITORS A IC Z K U Ardis O’Meara, MA • MANAGING EDITOR E T R I “Now more than ever, nurses are called upon to lead efforts to embed evidence-based practice in daily operations. As • • the IOM report states, ‘nurses have key roles to play as team members and leaders for a reformed and better-integrated, G F O U RT H E D I T I O N patient-centered health care system.’ The process of implementing sweeping change in health care will likely take years; however, nurses must start pragmatically and focus on these critically important protocols that have demonstrated improved E outcomes for older adults. Simply stated, ‘Pick this book up and use it.’” R F —Susan L. Carlson, MSN, APRN, ACNS-BC, GNP-BC, FNGNA President, National Gerontological Nursing Association OPIE EVIDENCE-BASED From the Foreword R AV R B TID GERIATRIC NURSING “As a gerontological clinical educator/research nurse, I will often use this as a reference. The format and the content are O good, and the explanations of how to best use the evidence simplify the process of sifting through mountains of information E RE to figure the best practice.” STIN T —Doody’s, Score: 97; 5 Stars OCC PROTOCOLS P E One of the premier reference books for geriatric nurses in hospital, long-term, and community settings, this RCN- B fourth edition has been thoroughly updated to provide the most current, evidence-based protocols for care AO UA of common clinical conditions and issues in elderly patients. Designed to improve the quality, outcomes, and C cost-effectiveness of health care, these guidelines are the result of collaboration between leading practitioners and L S FOR BEST PRACTICE T R educators in geriatric nursing and New York University College of Nursing. IS E C SD Protocols for each clinical condition have been developed by experts in that particular area, and most have been E I systematically tested by over 300 participating hospitals in “Nurses Improving Care for Health System Elders” N (NICHE). Evidence is derived from all levels of care, including community, primary, and long-term care. A MARIE BOLTZ G systematic method in compliance with the AGREE appraisal process was used to rate the levels of evidence for each ELIZABETH CAPEZUTI protocol. Protocols are organized in a consistent format for ease of use, and each includes an overview, evidence- based assessment and intervention strategies, and an illustrative case study with discussion. Additionally, each TERRY FULMER protocol is embedded within chapter text, which provides the context and detailed evidence for the protocol. Each F chapter contains resources for further study. O DEANNE ZWICKER U EDITORS KEY FEATURES: R T • Updated to provide a wide range of evidence-based geriatric protocols for best practices ARDIS O’MEARA H • Contains new chapters on function-focused care, catheter-associated urinary tract infections, mistreatment Managing Editor detection, acute care models, and transitional care E • Illustrates application of clinical protocols to real-life practice through case studies and discussion D • Edited by nationally known leaders in geriatric nursing education and practice, who are endorsed by the I T Hartford Institute for Geriatric Nursing and NICHE I • Encompasses the contributions of 58 leading practitioners of geriatric care O • Written for nursing students, nurse leaders, and practitioners at all levels, including those in specialty roles N ISBN 978-0-8261-7128-3 11 W. 42nd Street New York, NY 10036-8002 9 780826 171283 www.springerpub.com Evidence-Based Geriatric Nursing Protocols for Best Practice Marie Boltz, PhD, RN, APRN-BC, is an assistant professor at New York University (NYU) where she has directed the undergraduate course in Nursing Care of Adults and Elders. Dr. Boltz is also practice director of the NICHE (Nurses Improving Care for Healthsystem Elders) program, which is the only national nursing program designed to improve care of the older adult patient. Her areas of research are the geriatric care environment including measures of quality, the geriatric nurse practice environment, and the prevention of functional decline in hospitalized older adults. She has presented nationally and internationally and authored and coauthored numerous journal publications, organi- zational tools, and book chapters in these areas. Dr. Boltz is a John A. Hartford Foundation Claire M. Fagin fellow and the 2009–2010 American Nurses Credentialing Center (ANCC) Margretta Madden Styles Credentialing scholar. Elizabeth Capezuti, PhD, RN, FAAN, is the Dr. John W. Rowe Professor in Successful Aging at the College of Nursing at NYU. She also serves as codirector for the Hartford Institute for Geriatric Nursing where she directs the research center. She is an internationally recognized geriatric nurse researcher, known for her work in improving the care of older adults by interventions and models that positively influence a health care provider’s knowledge and work environment. Her current stud- ies focus primarily on translating effective interventions into actual practice, specifically, testing of new technologies for promoting independence and system change approaches to transform provider behavior. A recipient of more than $8 million in research and training grants, she has disseminated the findings of 35 funded projects in four coedited books and more than a hundred peer reviewed articles and book chapters. Dr. Capezuti received her doctoral degree in nursing from the University of Penn- sylvania in 1995. She joined the NYU faculty in 2003 and was promoted to professor in 2008. She has also been on the faculty of the University of Pennsylvania School of Nursing from 1984 to 2000 where she received the 1995 Provost’s Award for Distinguished Teaching. From 2000 to 2003, she held the Independence Foundation—Wesley Woods Chair in Gerontologic Nursing at Emory Uni- versity. She is a fellow of the American Academy of Nursing, the Gerontological Society of America, the American Association of Nurse Practitioners, and the New York Academy of Medicine. Terry Fulmer, PhD, RN, FAAN, is the dean of the Bouvé College of Health Sciences at North- eastern University. She received her bachelor’s degree from Skidmore College, her master’s and doc- toral degrees from Boston College, and her Geriatric Nurse Practitioner Post-Master’s Certificate from NYU. Dr. Fulmer’s program of research focuses on acute care of the elderly and, specifically, elder abuse and neglect. She has received the status of fellow in the American Academy of Nursing, the Gerontological Society of America, and the New York Academy of Medicine. She completed a Brookdale National Fellowship and is a distinguished practitioner of the National Academies of Practice. Dr. Fulmer was the first nurse to be elected to the board of the American Geriatrics Society and the first nurse to serve as the president of the Gerontological Society of America. DeAnne Zwicker, DrNP, APRN, BC is an ANCC certified adult nurse practitioner and is currently working as independent geriatric consultant. She completed her doctor of nursing practice (DrNP) in 2010 with a primary focus as a clinical scientist and secondary in education at Drexel University in Philadelphia. Her dissertation was entitled Preparedness, Appraisal of Behaviors, and Role Strain in Dementia Family Caregivers and the Caregiver Perspective of Preparedness and was a mixed-method study. She was a coeditor and chapter author for the fourth edition of Evidence-based Geriatric Nurs- ing Protocols (in press) as well as the third edition (2008), and managing editor for the second edi- tion (2003). She has served as the content editor of www.ConsultGeriRN.org since its inception. She recently instituted the NICHE program at Washington Hospital Center, which was awarded national NICHE designation. Ms. Zwicker has been a registered nurse for 32 years, with clinical practice experience as a geriatric nurse practitioner since 1992 in primary care, subacute care, long- term care, and clinical expert consultant in geriatrics. She has also taught nursing at the graduate level at NYU and Drexel University. Her areas of interest in geriatrics include proactive interventions in older adults, including prevention of adverse drug events and iatrogenesis in persons with dementia and prevention and/or early recognition of delirium. Ardis O’Meara, MA manages Geriatric Nursing, Heart and Lung: The Journal of Acute and Critical Care, and other geriatric nursing books. Her experience includes cardiology and research. Evidence-Based Geriatric Nursing Protocols for Best Practice 4th Edition Marie Boltz, PhD, RN, APRN-BC Elizabeth Capezuti, PhD, RN, FAAN Terry Fulmer, PhD, RN, FAAN DeAnne Zwicker, DrNP, APRN, BC EDITORS Ardis O’Meara, MA MANAGING EDITOR Copyright © 2012 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permis- sion of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or on the web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Margaret Zuccarini Composition: Absolute Service, Inc. ISBN 978-0-8261-7128-3 E-book ISBN: 978-0-8261-7129-0 11 12 13 / 5 4 3 2 1 The author and the publisher of this work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and the publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Evidence-based geriatric nursing protocols for best practice / [edited by] Marie Boltz ... [et al.]. — 4th ed. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8261-7128-3 — ISBN 978-0-8261-7129-0 (e-book) I. Boltz, Marie. [DNLM: 1. Geriatric Nursing—methods. 2. Nursing Care. 3. Aged. 4. Evidence-Based Nursing. 5. Nursing Assessment. WY 152] 618.97’0231—dc23 2011038613 Special discounts on bulk quantities of our books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. If you are interested in a custom book, including chapters from more than one of our titles, we can provide that service as well. For details, please contact: Special Sales Department, Springer Publishing Company, LLC 11 West 42nd Street, 15th Floor, New York, NY 10036-8002 Phone: 877-687-7476 or 212-431-4370 Fax: 212-941-7842 Email: [email protected] Printed in the United States of America by Bang Printing Contents Contributors vii Foreword xi Susan L. Carlson Acknowledgments xiii Introduction xv 1. Developing and Evaluating Clinical Practice Guidelines: A Systematic Approach 1 Rona F. Levin and Susan Kaplan Jacobs 2. Measuring Performance, Improving Quality 11 Lenard L. Parisi 3. Age-Related Changes in Health 23 Constance M. Smith and Valerie T. Cotter 4. Sensory Changes 48 Pamela Z. Cacchione 5. Excessive Sleepiness 74 Eileen R. Chasens and Mary Grace Umlauf 6. Assessment of Physical Function 89 Denise M. Kresevic 7. Interventions to Prevent Functional Decline in the Acute Care Setting 104 Marie Boltz, Barbara Resnick, and Elizabeth Galik 8. Assessing Cognitive Function 122 Koen Milisen, Tom Braes, and Marquis D. Foreman 9. Depression in Older Adults 135 Theresa A. Harvath and Glenise L. McKenzie 10. Dementia 163 Kathleen Fletcher 11. Delirium 186 Dorothy F. Tullmann, Kathleen Fletcher, and Marquis D. Foreman 12. Iatrogenesis: The Nurse’s Role in Preventing Patient Harm 200 Deborah C. Francis and Jeanne M. Lahaie 13. Physical Restraints and Side Rails in Acute and Critical Care Settings 229 Cheryl M. Bradas, Satinderpal K. Sandhu, and Lorraine C. Mion 14. Pain Management 246 Ann L. Horgas, Saunjoo L. Yoon, and Mindy Grall 15. Fall Prevention: Assessment, Diagnoses, and Intervention Strategies 268 Deanna Gray-Miceli and Patricia A. Quigley v vi Contents 16. Preventing Pressure Ulcers and Skin Tears 298 Elizabeth Ann Ayello and R. Gary Sibbald 17. Reducing Adverse Drug Events 324 DeAnne Zwicker and Terry Fulmer 18. Urinary Incontinence 363 Annemarie Dowling-Castronovo and Christine Bradway 19. Catheter-Associated Urinary Tract Infection Prevention 388 Heidi L. Wald, Regina M. Fink, Mary Beth Flynn Makic, and Kathleen S. Oman 20. Oral Health Care 409 Linda J. O’Connor 21. Managing Oral Hydration 419 Janet C. Mentes 22. Nutrition 439 Rose Ann DiMaria-Ghalili 23. Mealtime Difficulties 453 Elaine J. Amella and Melissa B. Aselage 24. Family Caregiving 469 Deborah C. Messecar 25. Issues Regarding Sexuality 500 Meredith Wallace Kazer 26. Substance Misuse and Alcohol Use Disorders 516 Madeline Naegle 27. Mistreatment Detection 544 Billy A. Caceres and Terry Fulmer 28. Health Care Decision Making 562 Ethel L. Mitty and Linda Farber Post 29. Advance Directives 579 Ethel L. Mitty 30. Comprehensive Assessment and Management of the Critically Ill 600 Michele C. Balas, Colleen M. Casey, and Mary Beth Happ 31. Fluid Overload: Identifying and Managing Heart Failure Patients at Risk for Hospital Readmission 628 Judith E. Schipper, Jessica Coviello, and Deborah A. Chyun 32. Cancer Assessment and Intervention Strategies 658 Janine Overcash 33. Acute Care Models 670 Elizabeth Capezuti, Marie Boltz, and Cynthia J. Nigolian 34. Transitional Care 682 Fidelindo Lim, Janice Foust, and Janet Van Cleave Index 703 Contributors Elaine J. Amella, PhD, RN, FAAN Professor, Medical University of South Carolina, Mt. Pleasant, SC Melissa B. Aselage, MSN, RN-BC, FNP-BC Lecturer, University of North Carolina, Wilmington, NC Elizabeth Ann Ayello, PhD, RN, APRN, BC, CWOCN, FAPWCA, FAAN President, Ayello, Harris & Associates, Inc., Clinical Associate Editor, Advances in Skin & Wound Care, Faculty, Excelsior College, School of Nursing, Executive Editor, Journal of World Council of Enterostomal Therapists Michele C. Balas, PhD, RN, APRN-NP, CCRN Assistant Professor, University of Nebraska Medical Center (UNMC), Omaha, NE Marie Boltz, PhD, RN, APRN-BC Assistant Professor, New York University, New York, NY Cheryl M. Bradas, RN, MSN, GCNS-BC, CHPN Geriatric Clinical Nurse Specialist, MetroHealth Medical Center, Cleveland, OH Christine Bradway, PhD, RN, CRNP Assistant Professor, University of Pennsylvania, Philadelphia, PA Tom Braes, RN, MSN Managing Director, Nursing Home Zoniën, OCMW Tervuren, Belgium Pamela Z. Cacchione, PhD, RN, GNP-BC Associate Professor, University of Pennsylvania, Philadelphia, PA Elizabeth Capezuti, PhD, RN, FAAN Dr. John W. Rowe Professor in Successful Aging at the College of Nursing, New York University, New York, NY Billy A. Caceres, RN, BSN, BA Research Assistant, New York University, New York, NY Colleen M. Casey, PhD, MS, RN, CCRN, CNS Nurse Practitioner, Internal Medicine and Geriatrics Oregon Health Sciences University Healthcare Eileen R. Chasens, DSN Assistant Professor, University of Pittsburgh, Pittsburgh, PA Deborah A. Chyun, MSN, PhD, RN Associate Professor, Yale University, New Haven, CT Valerie T. Cotter, DrNP, CRNP, FAANP Advanced Senior Lecturer, University of Pennsylvania School of Nursing, Philadelphia, PA Jessica Coviello, MSN, APRN Associate Professor, Yale University, New Haven, CT Rose Ann DiMaria-Ghalili, PhD, RN, CNSN Associate Professor, Drexel University, Philadelphia, PA vii viii Contributors Annemarie Dowling-Castronovo, MA, RN, GNP Assistant Professor, Wagner College, Staten Island, NY Regina M. Fink, RN, PhD, FAAN, AOCN Research Nurse Scientist, University of Colorado Hospital, Aurora, CO Kathleen Fletcher, RN, MSN, APRN-BC, GNP, FAAN Administrator of Senior Services, University of Virginia Health System, Charlottesville, Virginia. Marquis D. Foreman, PhD, RN, FAAN Professor and Chairperson, Rush University, Chicago, IL Janice Foust, PhD, RN Assistant Professor, University of Massachusetts, Boston, MA Deborah C. Francis, RN, MSN, GCNS-BC Geriatric Clinical Nurse Specialist, Kaiser Permanente Medical Center, South Sacramento, CA Terry Fulmer, PhD, RN, FAAN Dean of the Bouvé College of Health Sciences, Northeastern University, Boston, MA Elizabeth Galik, PhD, CRNP Assistant Professor, University of Maryland, Baltimore, MD Mindy Grall, PhD, APRN, BC Advanced Registered Nurse Practitioner, Baptist Medical Center, Jacksonville, FL Deanna Gray-Miceli, PhD, GNP-BC, FAANP Assistant Professor, Rutgers University, New Brunswick, NJ Mary Beth Happ, PhD, RN, FAAN Professor, University of Pittsburgh, Pittsburgh, PA Theresa A. Harvath, PhD, RN, CNS, FAAN Professor, Oregon Health & Science University, Portland, OR Ann L. Horgas, PhD, RN, FGSA, FAAN Associate Professor, University of Florida, Gainesville, FL Susan Kaplan Jacobs, MLS, MA, RN, AHIP Health Sciences Librarian/Associate Curator, Elmer Holmes Bobst Library, New York University, New York, NY Meredith Wallace Kazer, PhD, APRN, A/GNP-BC Associate Professor, Fairfield University, Fairfield, CT Denise M. Kresevic, RN, PhD, GNP-BC, GCNS-BC Nurse Researcher, Louis Stokes Cleveland VAMC, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH Jeanne M. Lahaie, RN, MS, GCNS-BC Elder Life Nurse Specialist, Hospital Elder Life Program (HELP), California Pacific Medical Center, San Francisco, CA Rona F. Levin, PhD, RN Professor, Pace University and Visiting Faculty, Visiting Nurse Service of New York, New York, NY Fidelindo Lim, RN, MA Clinical Instructor, New York University, New York, NY Glenise L. McKenzie, RN, MN, PhD Assistant Professor, Oregon Health & Science University, Ashland, OR Contributors ix Mary Beth Flynn Makic, RN, PhD, CNS, CCNS, CCRN Research Nurse Scientist, University of Colorado Hospital and Assistant Professor, Adjoint, University of Colorado, Aurora, CO Janet C. Mentes, PhD, APRN, BC, FGSA Associate Professor, University of California, Los Angeles, Los Angeles, CA Deborah C. Messecar, PhD, MPH, GCNS-BC, RN Associate Professor, Oregon Health & Science University, School of Nursing, Portland, OR Koen Milisen, PhD, RN Professor, Katholieke Universiteit, Leuven, Belgium Lorraine C. Mion, PhD, RN, FAAN Independence Foundation Professor of Nursing, Vanderbilt University, Nashville, TN Ethel L. Mitty, EdD, RN Adjunct Clinical Professor, New York University, New York, NY Madeline Naegle, APRN, BC, PhD, FAAN Professor, New York University, New York, NY Cynthia J. Nigolian, RN, GCNS, BC NICHE Clinical Administrator, New York, NY Linda J. O’Connor, MSN, RNC, GCNS-BC, CLNC Assistant Administrator for Nursing and Hospital Affairs, Mount Sinai Hospital, New York, NY Kathleen S. Oman, RN, MS, PhD Research Nurse Scientist, Assistant Professor (Adjoint), University of Colorado Hospital, Aurora, CO Janine Overcash, PhD, GNP Assistant Professor, University of South Florida, Tampa, FL Lenard L. Parisi, RN, MA, CPHQ, FNAHQ Vice President, Quality Management/ Performance Improvement, Metropolitan Jewish Health System, Brooklyn, NY Linda Farber Post, JD, MA, BSN Director, Bioethics, Hackensack University Medical Center, Hackensack, NJ Patricia A. Quigley, PhD, MPH, APRN, CRRN, FAAN, FAANP Associate Chief, Nursing Service for Research, Health Service and Rehabilitation Research Center of Excellence: Maximizing Rehabilitation Outcomes and Associate Director, VISN 8 Patient Safety Center, James A. Haley VA Hospital, Tampa, FL Barbara Resnick, PhD, CRNP, FAAN, FAANP Professor and Sonya Ziporkin Gershowitz Chair in Gerontology, University of Maryland, Baltimore, MD Satinderpal K. Sandhu, MD Assistant Professor, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH Judith E. Schipper, MS, NP-C, CLS, FNLA, FPCNA Clinical Coordinator, Heart Failure Program, New York University Langone Medical Center, New York, NY R. Gary Sibbald, MD, FRCPC, ABIM, DABD, Med Director, Wound Healing Clinic, The New Women’s College Hospital and Professor, Public Health Sciences and Medicine, University of Toronto, Toronto, CA Constance M. Smith, PhD, RN Wilmington, DE Dorothy F. Tullmann, PhD, RN Assistant Professor, University of Virginia, School of Nursing, Charlottesville, VA