Introduction
The aging population remains a global phenomenon in the new millennium and will be a major problem in developing countries. Aging can be defined as a phenomenon of biology, sociology, economics, and chronology. The chronological definitions will be used, and according to the recommendations of the United Nations and the Ministry of Health, people older than 60 will be considered ‘old or elderly’ (Karim, 1997). Malaysia, which is known as a middle-income country with a population of 28 million, is not excluded. The population aged 60 years and above increased by 5.7% in 1990 to 6.3% in 2000 and is expected to be 9.8% by 2020 (Ambigga et al.,2011).
Life expectancy among Malaysians also increased to 71.7 years for men and 76.5 years for women in 2007. Despite the increase in life expectancy, the elderly population faces many problems, which are financial conditions, lack of education, and poor social support resulting from impacting the welfare of the elderly (Ambigga et al.,2011). However, community programs on health promotion are important for the elderly as this is useful for families with the elderly. It can be done by the community health nurse for the benefit of the elderly.
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Community health nurses are also known as public health nurses who are trained to work in public health settings such as health departments or districts, schools, prisons, and businesses because of their role in the community as caregivers, often they form a close link in their community and become field experts, especially in health and wellness. Community nursing integrates evidence-based research with the health needs of the community to provide care based on evidence.
They must specify the cultural and socioeconomic needs of the community and align the care as necessary. The aging process is usually associated with normal physiological and biological degradation that makes the body more susceptible to diseases and infections. In addition, environmental and material exposure is another contributing factor. Therefore, more parents have chronic illnesses and health problems due to this phenomenon. Hence the demand for healthcare facilities for the elderly increased.
Health Promotion on the Elderly
Health promotion is intended for the whole population, but however, health promotion strategies for the elderly generally have three basic objectives, namely to maintain and enhance functional capabilities, maintain or enhance personal care and stimulate social networks. The idea behind this strategy is to contribute to a longer, independent and self-sufficient quality of life. There is enough evidence to support the claim that social relationships and social activities are important for healthy aging (Golinowska, Groot, Baji, & Pavlova, 2016). Health promotion is 2.1 Hypertension and Diabetes mellitus Both hypertension and diabetes mellitus are important health issues that affect the elderly.
Both of these diseases are interconnected, so one study shows a significant relationship between diabetes mellitus and hypertension. People with diabetes are twice as likely to have hypertension as those who do not. First, health promotions, such as regular medical tests or screenings for parental health, can be done to monitor blood pressure and for early detection of any new cases of high blood pressure. It is an important step that should be taken to increase health awareness and prevent disease in people aged 60 years or older. Hypertension detection in the elderly can reduce morbidity and mortality due to hypertension and, therefore, will improve the quality of life.
On the other hand, an active screening program is required to detect people with diabetes mellitus and also decreased glucose tolerance which then leads to diabetes mellitus. Early detection through regular health screening can also lead to early management and treatment that will then reduce morbidity and mortality among the elderly ( Lisa & Noran, 2014). Secondly, health promotion can be done by raising awareness of hypertension and diabetes mellitus among older adults through health education.
As the study says, most parents do not know their high blood pressure and, therefore, do not take precautionary measures to control their nutritional intake as well as their participation in physical activity. Similarly, those with uncontrolled blood pressure do not know about the importance of compliance with hypertension drugs. Those with diabetes have similar problems that show less awareness among them. Health education can be done during your visit to health checks or by organizing discussions with the rural community.
Awareness can be enhanced in primary prevention strategies, such as promoting a low salt diet, sugar intake control, and increased physical activity to reduce the prevalence rate of hypertension ( Lisa & Noran, 2014). 2.2 Sensory impairment Promotion and health counseling related to vision and loss of hearing are more focused on preventative measures, emphasizing early detection and treatment, regular checks, or visual acuity testing. Devices such as glasses, lenses, or hearing aids with special prescriptions to reduce non-compliance increase the effectiveness of treatment.
For example, cataracts can be removed by surgery, and that person can restore their vision, while for patients with known diabetes mellitus cases, vision checks should still be performed to prevent irreversible complications such as diabetic and blind retinopathy. In addition to hearing problems, avoid prolonged exposure to loud sounds or use protective devices such as earplugs to minimize effects or delay hearing problems. Advise them to seek immediate medical attention if there is any incredible feeling or abnormalities in their vision or hearing ( Lisa & Noran, 2014).
Musculoskeletal Osteoporosis, joint pain, arthritis, hip fracture, decreased muscle mass, and strength are musculoskeletal problems. Adequate calcium intake through dietary supplements or supplements is important to prevent Osteoporosis. People must be active and work out to maintain tone and muscle strength, in addition to preventing injuries and falls. Stop smoking and reduce alcohol or food intake to reduce the risk of Osteoporosis. Regular density checks and assessments. Public amenities and amenities, such as housing, transport, and hospitality, should be friendly to parents to help parents with decreased musculoskeletal function ( Lisa & Noran, 2014).
Depression and Dementia Implementing social and health programs for seniors and caregivers can provide a way for them to relieve their stress and fatigue. The deterioration and pressure of guards are major causes of abuse and abuse among the elderly. Treating older people with cognitive disorders is not as easy as people think and really affects families and societies in terms of physical, psychological, and financial. Furthermore, maintaining physical and aerobic fitness among the elderly with a ten-step test to check their dexterity, a short physical performance battery, such as running speed, chair and balance to measure their dynamic balance, etc. they can prevent cognitive impairment, as well as adopt a healthy lifestyle in the elderly to improve their cardiovascular system.
On the other hand, he emphasizes the institutionalization of parental and functional financial institutions ( Lisa & Noran, 2014). In addition, the Asian community recognizes that children should take care of their old parents and meet their needs in relation to the piety of children who are no longer applicable to the majority of society since childhood work and also due to socio-demographic changes. The rehabilitation and nursery centers can be the best place, especially for elderly people who are depressed with chronic illness, rather than sending them to a nursing home or renaming a nursing home with adequate and well-trained services. Staff for senior management with chronic illness ( Lisa & Noran, 2014).
Appropriate Health Promotion and Identified Activity for Implementation
Health promotion is very important for the elderly, but before planning, it is very important to have the activities as below. 3.1 Conducting an assessment of needs Determination of the scope of the assessment is very important. The purpose of the assessment is to determine who will take part and which organization is interested, and the decision will be based on the evaluation requirement. Decision-making should be based on what information is needed and the need to think carefully and critically (Egyetem, 2015). 3.2 Gathering data The needed data only should be gathered and which is considered culturally appropriate. Data-gathering approaches are tailored to the target population and setting. The data will be divided into two, which are primary data and secondary data.
Primary data collection is normally the new data that never existed and is normally obtained directly from surveys, interviews, focus groups, and direct observation. Primary data is considered expensive and more time-consuming compared to secondary data. Secondary data is easier because the data already exist from vital records, census data, and peer-reviewed journals. Some information may not exist for some settings because the data may be old or the data may not have been correctly collected (Egyetem, 2015). 3.3 Data analysis should be done and analyzed as descriptive after considering the discussion and decision on the program priorities, grouping data by the types of death or disability, behavioral risk factors, and non-behavioral risk factors like social, physical, and environmental factors. The factors to consider in establishing program priorities at a site (Egyetem, 2015).
How large is the discrepancy between the incidence of the health problem at local, state, or national levels? b.How many elderly are affected by health problems? c.Which problem has the greatest impact on disability or mortality? d.What are the leading perceived health problems of the stakeholder, e? What will be the consequences if the health problem is not corrected? f.Would not correcting the problem cause other health-related problems? g.Would other health-related problems be reduced if this health problem were reduced? h.What is the potential impact on others at the site if the health problem is reduced? How difficult would it be to correct the health problem? j.Which problems are already being addressed by other groups and organizations? How many resources would be required to solve the problem?
How effective are available interventions in preventing or reducing health-related problems? m.Do you have the expertise to resolve health-related problems? n.What are the barriers (obstacles) to correcting the health-related problem? o.Will the stakeholders want and accept the proposed solution to the health-related problem? p.Do current laws permit the proposed health-related program activities to be conducted? Report and share the findings Preparing a report is a very important task. The entire report should be printed. Then preparing special reports or brochures for particular groups of individuals and stakeholders such as funders or program participants. Then, informing people about the report through e-mail, public meetings, and board and staff meetings (Egyetem, 2015). Set a goal for health promotion Setting a goal is a broad statement that describes the desired longer-term impacts of what you want to accomplish (Egyetem, 2015). Set a program’s direction and intent so that it can provide the foundation for specific objectives and activities.
Clarify what is important in the health promotion program and state the end results of the program, which will include the program’s target population by using action words such as reduce, eliminate, or increase, like setting a goal of the ‘healthy lifestyle promotes healthy living.’ The objective of the health promotion Objective or desired outcomes is the specific changes expected in your target population as a result of your program. There are some specific steps that need to be achieved in order to attain the goal. The specific objective statement specifies who, what, when, where, how much, how many, or how often. It should be measurable (Egyetem, 2015).
Logic model application In Program Design and Planning, a logic model function as a planning tool to develop program strategy and improve the ability to clearly explain and illustrate program concepts and approach for key stakeholders, including funders. In Program Implementation, a logic model forms the core of a focused management plan that helps you identify and collect the data needed to monitor and improve programming. Finally, in Program Evaluation and Strategic Reporting, a logic model presents program information and progress toward goals in ways that inform, advocate for a particular program approach, and teach program stakeholders (Egyetem, 2015).
The Role and Responsibility of Community Health Nurse
Disease prevention specialist – community health nurses focus on long and short-term care for disease prevention so that elderly patients can live a quality life. They work with elderly patients from day one so that they will be able to support self-management and improve healthy lifestyles so that all the elderly can have a quality life while aging (Tornyay, 1980). For example, have free screening for an elderly patients, especially after the age of 60 years old, so that the nurses can be able to identify which patient needs treatment, which patient requires dietitian follow-up, or which patient requires to have cardiovascular follow-up so that earlier detection can prevent mortality and as well morbidity among elderly patients.
Community educator – as an educator, community health nurses focus on presenting materials in a clear and understandable format so that the elderly patients understand what they are being educated for and why for better understanding. They provide information to everyone, not only to individuals but as well to families and communities, so that they can create a framework for healthy living and healthy choices. In public, they often hold campaigns and seminars on diabetes management because most of the elderly patients have diabetes; the campaign is always to control diabetes by how to be compliant with the medications and regular follow-ups.
Overall, they focus on community health education as a step toward preventive health care (Tornyay, 1980). it is important to prevent the disease if possible because prevention is always better than cure. c.Leader – Community health nurses use evidence to implement policy changes and quality-based practices. They lead collaborative efforts to produce successful health outcomes and provide critical medical and social services in communities (Tornyay, 1980). Community health nurses can’t be a leader without collaborating with other teams or departments because health promotions in community settings require collaboration.
For example, having screening tests for free for the elderly with physical activities for them requires the community health team to collaborate with the medical team, pharmacist, occupational therapist, dietitian, and others who are involved so that the health promotion which is organized goes as planned. That is when a community need to become a leader to arrange and decide what assignment will be done by each team for smoothness of the health promotion. d.Researcher – as a researcher, community health nurses collect and use evidence to execute positive changes for better health. Research is used to validate funding for public health programs, reduce inequalities in health care, and increase access to services (Tornyay, 1980).
The responsibility of a community health nurse is to collect data which is done almost every month. That evidence will then be used for research so that it can bring positive changes in elderly health. Like for example, when having screening tests among elderly patients, the data will be used to identify the disease currently faced by the patients, like 75% of elderly patients in Klinik Buntong suffering from diabetes. Then as a researcher, we can identify risk factors associated with the disease. e.Advocate – community health nurses advocate on the local, state, and federal levels to provide better access to health care, protect funding for public health programs, and reduce or eliminate health disparities.
They help families arrange assistance through social services programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides healthcare and nutritional services for low-income pregnant women, breastfeeding mothers, and children under age 5 (Tornyay, 1980). f.Caregiver – a community nurse with cross-cultural, language, and literacy boundaries to shape the health and well-being of children and adults. They provide prenatal care and education for expectant mothers, including information about maternal nutrition, referrals for childbirth classes, and postpartum assistance. They also provide resources for parents to understand proper childhood development and discipline techniques(Tornyay, 1980).
Conclusion
In conclusion, the population in Malaysia is aging, and it is inevitable. The elderly people are less healthy than the younger age groups. Therefore, an increase in the spread of the disease is associated with an increase in the age group. The health problems that are common among older people are hypertension, diabetes mellitus, dementia, depression, urinary incontinence, sensory disorders, and musculoskeletal problems such as arthritis. Therefore, to promote health and quality of life, this strategy must be implemented effectively to achieve healthy and successful aging. Finally, communities and authorities must share responsibility for promoting health among the elderly in Malaysia.
Pharmacological Management Of Postoperative Pain In Neonates Using Morphine
Pharmacological treatment for postoperative pain for a term neonate
The treatment of postoperative pain for this term infant after a jejunal atresia repair is a continuous dose of morphine through intravenous access, either a peripheral IV or a PICC line. The assumption is that this surgery was not done laparoscopically, and the surgeons made an abdominal incision while in the operating room. The dosing for this neonate will begin at 0.02 mg/kg/hour due to the hypotension that the patient had when he came back from OR (Taketomo, Hadding, & Kraus, 2019). The drip will be titrated accordingly to maintain a therapeutic effect. PRN dosing is available with an indication of mild to moderate pain at 0.02 mg/kg/dose every hour if needed.
Appropriate dosing for acetaminophen
Acetaminophen will be used in conjunction with morphine for postoperative pain. The acetaminophen will be given intravenously as well. A set dose of 10 mg/kg every 6 hours will be given for 72 hours. A maximum dose of 40 mg/kg/day should not be exceeded due to the potential for hepatotoxicity (Taketomo, Hadding, & Kraus, 2019).
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Therapeutic category and adverse effects of morphine and acetaminophen in the neonatal population
Morphine is considered an opioid analgesic. This drug can have significant adverse effects that the patient will be routinely monitored for post-operatively. A black box warning indicates that a chance of serious and life-threatening respiratory depression may occur. Hypotension is another significant adverse reaction that could affect this patient (Taketomo, Hadding, & Kraus, 2019).
Hypersensitivity is always a concern when starting a new medication. If hypersensitivity does occur, discontinuation of the drip is warranted, and additional pain management options should be explored. Morphine used for postoperative pain management in this patient may also cause decreased bowel motility, urinary retention, ureteral spasms, and oliguria (Taketomo, Hadding, & Kraus, 2019).
Acetaminophen has many adverse reactions as well. Two black box warnings for this drug pertain to the care of this neonate. The first black box warning enforces the need for correct dosing, ensuring that a dose in milligrams (mg) is not confused with milliliters (mL), that dosing of patients under 50 kilograms (kg) is based on weight, that infusion pumps are set correctly, and that the daily doses do not exceed the recommended daily maximum dose (Taketomo, Hadding, & Kraus, 2019).
The second black box warning explains that acetaminophen can be associated with acute liver failure. Hepatotoxicity is usually associated with excessive intake of the drug from multiple sources. Again, it is important not to exceed the maximum daily dosing of the medication from all sources that the patient is ordered (Taketomo, Hadding, & Kraus, 2019). Other adverse effects that the patient will be monitored for include hypotension and tachycardia, agitation, oliguria, atelectasis, and fever. Additionally, acetaminophen can cause electrolyte imbalances, including hypokalemia, hypomagnesemia, and hypophosphatemia (Taketomo, Hadding, & Kraus, 2019).
Mechanism of action for morphine and acetaminophen
Morphine binds to opioid receptors in the central nervous system. This causes the inhibition of ascending pain pathways, which alters the perception of and response to pain. It also produces generalized central nervous system depression (Taketomo, Hadding, & Kraus, 2019). The mechanism of action for acetaminophen is not completely understood. It is believed that the analgesic effects are caused by the activation of the descending serotonergic inhibitory pathways in the central nervous system.
There is some thought that there is some interaction with other nociceptive systems as well (Taketomo, Hadding, & Kraus, 2019). The hope is that the use of acetaminophen in conjunction with morphine will decrease the amount of opioid analgesic needed for effective pain management in this patient. Studies show that using acetaminophen as an adjunct to morphine improves overall pain scores and reduces the amount of time spent on opioids (Jelacic et al., 2016).
Monitoring effective pain management
Initially, vital signs are a great indicator of any pain that the sedated and paralyzed patient may feel. The patient’s heart rate and blood pressure will be high if there is a presence of pain. Unfortunately, the patient’s high heart rate and low blood pressure indicate that he may be hypovolemic. It is important that this is corrected before relying on these indicators for pain. After the paralytic and sedative wear off from surgery, the addition of a pain scale will be helpful in assessing any pain the patient may have.
The NPASS (Neonatal Pain/Agitation/Sedation scoring) is a pain scale that will be used to assess the pain and sedation level of the infant by looking at crying and irritability, behavior state, facial expressions, extremities tone, vital signs, and a premature pain assessment by rating each category from 0 to 2 (Hummel et al., 2008). If scoring higher than a 4, which is considered mild to moderate pain, a PRN dose of morphine may be indicated. Depending on how many morphine boluses are given in a twelve-hour period, an increase in the continuous drip dose may be needed to maintain a therapeutic effect.
Additional therapeutic considerations
There are significant considerations that need to be addressed for this patient. The most pressing and important one is that he is potentially hypovolemic. His high heart rate and low blood pressure are indicators that he may need a bolus of normal saline 10 mL/kg. It is important that this is corrected. Because of the infant’s current hypotension, the morphine drip was started at a lower dose. Hopefully, by doing this, any additional hypotension can be avoided. Antibiotics post-operatively would be ordered as well. This patient will receive Zosyn at 80 mg/kg/dose every 6 hours for seven days.
Zosyn has a broad-spectrum antimicrobial effect that covers gram-negative, gram-positive, and anaerobes. It is commonly used for intrabdominal infections (Taketomo, Hadding, & Kraus, 2019). A blood gas would be needed to check the appropriateness of the ventilator settings that the patient is currently on post-operatively. The patient would also be on servo mode under the radiant warmer to maintain normothermia. Hypothermic infants tend to experience more adverse events that require more supportive interventions during the postoperative period than normothermic infants (Hedwig S. et al., 2016).
Scope of Practice determinants for NNPs to prescribe
Largely, the state governments decide the scope of practice for any type of APRN. In Ohio specifically, the Ohio Revised Code (ORC) is a compilation of all the laws in Ohio that are written by the state legislature. The Ohio Administrative Code (OAC) is the rules and regulations that further break down and define those laws (OAAPN, 2018).
The Committee on Prescriptive Governance (CPG) updates the format of the prescriptive formulary and develops recommendations that pertain to the authority of prescribing certain drugs and therapeutic devices. The Ohio Board of Nursing (OBN) will adopt rules as necessary in order to implement provisions regarding the authority of clinical APNs to prescribe. These rules are consistent with the recommendations the OBN receives from the CPG (OAAPN, 2016).
Rules of prescriptive authority for NNPs in Ohio
According to the APRN Consensus Model from the NCSBN, neonatal nurse practitioners must have a written collaborative agreement and direct supervision by a licensed MD, DO, DDS, or podiatrist in order to prescribe (2020). This is known as a standard care arrangement (SCA). These agreements will outline the physician-practitioner relationship and must be reviewed and signed every two years and include off-label and schedule II prescribing authority (OAAPN, 2018).
In 2017, the need to obtain a certificate of authority (COA) and a certificate to prescribe (CTP) was removed, and the new APRN licensure was created. This allows for role designation between certified registered nurse anesthetists (CRNA), certified nurse-midwives (CNM), clinical nurse specialists (CNS), and certified nurse practitioners (CNP). As part of the new law, an exclusionary-only drug formulary was established to specify the drugs that APRNs are not authorized to prescribe (Cleveland Clinic, 2017).
Legal and Professional guidelines that affect the NNP role
The NNP must be aware of and educated on current literature and practices regarding the medications they prescribe, including safety alerts and recalls. It is also imperative that they stay up to date on all certifications and continuing education in order to legally prescribe and practice as an NNP. Certifications must be verified by the Ohio Board of Nursing. Currently, twelve hours of continuing education are needed every two years in regard to the pharmacology aspect of their practice (OAAPN, 2018).
A nurse practitioner should always prescribe within their correct scope of practice. The prescriber-patient relationship must be a valid one, and the nurse practitioner should obtain a history, conduct a physical exam, give a diagnosis, prescribe medications and rule out contraindications, consult with the collaborating physician, and document these steps in the medical record. Appropriate follow-up with these patients is necessary. OARRS reports should be run on every patient that receives a schedule II drug (OAAPN, 2018).
References
- Cleveland Clinic (2017). APRNs in Ohio Now Licensed: New ‘APRN Modernization’ Bill
became law in early April. https://consultqd.clevelandclinic.org/aprns-ohio-now-licensed/.
- Hedwig, S. et al. (2016.) Time Trends and Predictors of Abnormal Postoperative Body
The temperature in Infants Transported to the Intensive Care Unit. Anesthesiology Research and Practice. https://doi.org/10.1155/2016/7318137
- Hummel, P. et al. (2008). Clinical reliability and validity of the N-PASS: neonatal pain,
agitation, and sedation scale with prolonged pain. Journal of Perinatology, pp. 28, 55-60
https://doi.org/10.1038/sj.jp.7211861
- Jelacic, S. et al (2016). Intravenous Acetaminophen as an Adjunct Analgesic in Cardiac Surgery
Reduces Opioid Consumption But Not Opioid-Related Adverse Effects: A Randomized Controlled Trial. Journal of Cardiothoracic and Vascular Anesthesia, 30(4), 997-1004. https://doi.org/10.1053/j.jvca.2016.02.010
- National Council of State Boards of Nursing, Inc. (NCSBN). (2020). APN Consensus
Implementation Status. https://www.ncsbn.org/5397.htm.
- Ohio Associate of Advanced Practice Nurses (OAAPN). (2016). Prescriptive Authority
Reminders. Retrieved from https://oaapn.org/2016/04/prescriptive-authority-reminders/.
- Ohio Associate of Advanced Practice Nurses (OAAPN). (2018). APRN Practice Law Update
OAAPN 2018. [PowerPoint] Retrieved from https://cdn.ymaws.com/oaapn.site-ym.com/resource/resmgr/education/2018nwo/Law_and_Rule_Update.pdf.
- Taketomo, C., Hodding, J., Kraus, D. (2019). Lexicomp Pediatric & Neonatal Dosage
Handbook: An Extensive Resource for Clinicians Treating Pediatric and Neonatal Patients (26th Edition). Wolters Kluwer Clinical Drug Information, Inc.