Obesity is quickly becoming one of the most common chronic diseases among children. These rates have increased at an alarming rate and is a major public health problem because of related physical and psychological comorbidities, including type II diabetes, insulin resistance, metabolic syndrome, cardiovascular disease and mental health disorders. Dramatic increase in the number of overweight and obese children in recent years.
Studies indicate that children's lives may be shortened as a result of this alarming health problem. Estimates state that for any degree of overweight/obesity, younger adults (20-30 years of age) may have greater years of life lost due to obesity than older adults. Childhood obesity has been determined to be an independent risk factor for adult overweight/obesity.
To combat childhood obesity, there is a great need for public health interventions as well as education parents regarding childhood obesity and its consequences. Parents differ on causation of obesity, and differ in focus on nutrition and physical exercise. Many parents in the research do not see obesity as a barrier to physical activity. The parents need to recognize their child as overweight. Prevention is the most effective method for dealing with this growing health concern. The evidence reviewed, confirmed that family-centered interventions were associated with short-term reduction in obesity and improved medical parameters. The goal should be to involve community resources and provider referrals. Nurse Practitioners have a unique role in being the best facilitators to deliver health messages and are able to educate parents and increase awareness about the causes and consequences of childhood obesity.
Parents of young children need to interact with their child's primary healthcare provider for health advice and preventive health information during regularly scheduled physical examinations. It is up to the parents of these young children to combat intervention strategies such as:
a combination of nutritional and activity information, a cognitive-behavioral aspect to the intervention parent-directed activities
limiting sedentary child behaviors, provide positive approaches with children by parents and practitioners (e.g., emphasize positive rewards for healthy behaviors, encourage self-efficacy)
Future research is required to identify moderators and mediators to produce enduring changes in weight status of children.
The Objective was to determine in children who are at risk for becoming overweight or obese, does education with parental involvement on exercise and nutrition compared to individual education with the child alone decrease the risk of developing obesity and the health problems associated with obesity?
(P) In overweight, obese, or at risk young children (2-18years of age) Is family centered education/treatment interventions
(C) versus control or comparison interventions
(O) more effective in decreasing childhood obesity and compli.
Running head PICOT STATEMENT 1PICOT STATEMENT 5.docxtoltonkendal
Running head: PICOT STATEMENT 1
PICOT STATEMENT 5
PICOT Statement: Childhood Obesity
P-I-C-O-T Statement
P- Patients who suffer from obesity (BMI of more than 30)
I- Undertaking nutritional education, diet, and exercise
C- Comparison to nutritional education, endoscopic bariatric surgical intervention
O- Improved health outcomes in terms of overall weight
T - A year’s time limit
PICOT Statement: Childhood Obesity
Introduction
Childhood obesity poses serious health problems in the US as the number of overweight and obese population increases at a rapid pace every year. The effects of this problem have arrested the attention of policymakers, societal members, and government agencies. This has resulted in ranking childhood obesity as a national health concern. The adverse impacts of this disease go beyond the health realms to include economic burden on both personal and national budgets. While there are numerous risk factors and various evidence-based interventions to address this challenge, no single approach is consistently efficacious in curbing the disease. Consequently, it is imperative that efficacious initiatives and policies be developed to address the never-ending problem of childhood obesity. Multidisciplinary approaches are often broad and cut across all dimensions of personal health problems. Instead of placing emphasis solely on biomedical models, health care professionals should also seek to promote behavior change among obesity patients and their family members. A PICOT statement can be utilized as an effective tool to seek interventions of addressing childhood obesity.
PICOT Statement
Population
In the US, obesity prevalence is highest among children aged from 6 to 11 years (Cheung et al. 2016). The disease has tripled among this age group from 4.2 percent to 15.3 percent from 1963 to 2012. In the last three decades, increased cases of obesity prevalence have been noted among children of all ages, although the differences in obesity prevalence have been recorded in terms of age, race, ethnicity, and gender (Cheung et al. 2016). In this respect, children from socioeconomically disadvantaged families and some racial and ethnic minorities experience the higher median score on obesity than the dominant white population. Higher obesity rates are often recorded among blacks and Hispanics compared to whites. For instance, a survey on girls in the Southwest revealed that the yearly cases of obesity stood at 4.5 percent among Blacks, 2 percent among Hispanics, and 0.7 percent among white girls aged from 13 to 17 years (Cheung et al. 2016). For low-income earners, American Indians rank highest at 6.3 percent, followed closely by Hispanics at 5.5 percent.
Intervention
Evidence-based interventions that seek to reduce childhood obesity incidences in the country should target two major areas: prevention and treatment. High-quality RCT has been proven as one of the most effective preventative ...
Presentation on childhood obesity prevention in early childhood settings. Presented April 28, 2011 at the DOD/USDA Family Resilience conference, Chicago, IL.
Running head PICOT STATEMENT 1PICOT STATEMENT 5.docxtoltonkendal
Running head: PICOT STATEMENT 1
PICOT STATEMENT 5
PICOT Statement: Childhood Obesity
P-I-C-O-T Statement
P- Patients who suffer from obesity (BMI of more than 30)
I- Undertaking nutritional education, diet, and exercise
C- Comparison to nutritional education, endoscopic bariatric surgical intervention
O- Improved health outcomes in terms of overall weight
T - A year’s time limit
PICOT Statement: Childhood Obesity
Introduction
Childhood obesity poses serious health problems in the US as the number of overweight and obese population increases at a rapid pace every year. The effects of this problem have arrested the attention of policymakers, societal members, and government agencies. This has resulted in ranking childhood obesity as a national health concern. The adverse impacts of this disease go beyond the health realms to include economic burden on both personal and national budgets. While there are numerous risk factors and various evidence-based interventions to address this challenge, no single approach is consistently efficacious in curbing the disease. Consequently, it is imperative that efficacious initiatives and policies be developed to address the never-ending problem of childhood obesity. Multidisciplinary approaches are often broad and cut across all dimensions of personal health problems. Instead of placing emphasis solely on biomedical models, health care professionals should also seek to promote behavior change among obesity patients and their family members. A PICOT statement can be utilized as an effective tool to seek interventions of addressing childhood obesity.
PICOT Statement
Population
In the US, obesity prevalence is highest among children aged from 6 to 11 years (Cheung et al. 2016). The disease has tripled among this age group from 4.2 percent to 15.3 percent from 1963 to 2012. In the last three decades, increased cases of obesity prevalence have been noted among children of all ages, although the differences in obesity prevalence have been recorded in terms of age, race, ethnicity, and gender (Cheung et al. 2016). In this respect, children from socioeconomically disadvantaged families and some racial and ethnic minorities experience the higher median score on obesity than the dominant white population. Higher obesity rates are often recorded among blacks and Hispanics compared to whites. For instance, a survey on girls in the Southwest revealed that the yearly cases of obesity stood at 4.5 percent among Blacks, 2 percent among Hispanics, and 0.7 percent among white girls aged from 13 to 17 years (Cheung et al. 2016). For low-income earners, American Indians rank highest at 6.3 percent, followed closely by Hispanics at 5.5 percent.
Intervention
Evidence-based interventions that seek to reduce childhood obesity incidences in the country should target two major areas: prevention and treatment. High-quality RCT has been proven as one of the most effective preventative ...
Presentation on childhood obesity prevention in early childhood settings. Presented April 28, 2011 at the DOD/USDA Family Resilience conference, Chicago, IL.
Running head LITERATURE REVIEW 1LITERATURE REVIEW 5.docxcowinhelen
Running head: LITERATURE REVIEW 1
LITERATURE REVIEW 5
Literature Review
Name:
Institution:
Literature Review (Childhood Obesity)
Childhood Obesity describes attainments of weight beyond the normal body mass index ration leading to the vulnerability in lines. In the study, the use of article will facilitate the process. As noted, the researcher of the material sought to evaluate the factors that contribute to obesity in children. Their study focused on dieting and physical exercise as the primary factors that contribute to obesity. The researchers commenced the process by identifying the research question, proceeded with instruments then selected the design before engaging the target population to validate the research hypothesis. The target group for the study comprised of children aged below 12 years. They included children from a different racial background. Both boys and girls featured in the study. The researcher hypothesized the cause of obesity with the motive of encouraging the adaptation of intervention programs. The study prioritized preventive measures with the intent of decreasing cases of obesity in children in less than six months.
The literature for study includes article 1, 2, 3 and 4. Article 5, 6, 7 and 8 also featured in the study. The research sought to evaluate the prevailing trends concerning the wellness of the children using a collection of questions. The first article by Bleich, Segal, Wu, and Wilson& Wang sought to evaluate the role of community-based prevention. The second article by Tester et al examined the characteristics of the condition in children aged between 2 and 5. The third article by Cunningham, Kramer, & Narayan quantified the prevalence of the condition. Arthur, Scharf, and DeBoer’s fourth sought to evaluate the role of food insecurity in the contraction of obesity. The fifth and sixth Fetter et al and Lydecke, Riley, & Grilo examined the role of physical activity and parenting subsequently. The exploration of the implication of the limitation of the dietary behavior of the micro levels of the condition and parents understanding on the condition featured in the seventh and eight articles composed by Marcum, et al, and Vollmer respectively.
The sample population for the study in the first article comprised of the young population in homes school and care setting. The second article engaged children aged between 2 and 5 years. The third article engaged 7738 participants comprising of learners in kindergarten. The group in the early childhood stage featured in the fourth article as the sample population for the study seeking to investigate cases of obesity. The sample differed from the group engaged in the fifth and sixth article. The category interviewed comprised of the parents of the youth and pre-adolescents, the seventh and eight articles engaged the mothers of the children and the fathers averaging 35 years of white origin.
The limitation of the first article is that the resear ...
NEED BY 061220 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!.docxTanaMaeskm
NEED BY 06/12/20 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
Describes statistical significance to pediatric nursing grounded in scholarly literature. Collates utilized references and summarizes key points.
· Statistical significance-
· Key Points
***Need 1 scholarly source
Use the article attached the title is for this presentation:
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE?"
KEYPOINTS: answer theses questions and describe statistical data
· Childhood Obesity- What is their growth/BMI?
· Is there a pathophysiological dilemma such as Binge Eating Disorder (BED)?
· What are the cultural differences and customs to provide client centered quality care?
· How can we observe and assess what beliefs the client has on food choices and psychosocial needs?
· What are their cognitive level/ learning needs?
· What are their educational needs?
· What availability does client have to food and nutrition (economical status)?
· What are some healthy food choices and activity for better living?
· What can we provide as resources to client when there is economical hardships involved?
· What beliefs or morals are ok with you on this topic?
STATISTICAL SIGNIFICANCE:
** use the article attached and another scholarly source of choice if needed
APA FORMAT and intext citation
NEED BY
06/12/20 CST Chicago
, IL
t
ime
. NO
PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
Describes statistical significance to pediatric nursing grounded in scholarly literature. Collates utilized
references and summarizes key points.
·
Statistical significance
-
·
Key
Points
***
Need
1
scholarly source
Use the article attached the title is for this presentation
:
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE?"
K
EYPOI
NTS:
answer the
ses questions and describe stati
s
tical data
·
Childhood Obesity
-
What is their growth/BMI?
·
Is there a pathophysiological dilemma such as Binge Eating Disorder (BED)?
·
What are the
cultural differences and cus
toms to provide client centered quality care?
·
How can we observe and assess what beliefs the client has on food choices and psychosocial
needs?
·
What are their cognitive level/ learning needs?
·
What are their educational needs?
·
What availability does client have to food and nutrition (economical status)?
·
What are some healthy food choices and activity for better living?
·
What can we provide as resources to client when there is economical hardships involved?
·
W
hat
bel
iefs or morals are ok wi
th you on this t
opic?
STATISTIC
AL SIGNIF
ICANCE
:
** use the article attached and
another sch
olarly source o
f choice
if nee
ded
APA FORMAT and intext citation
NEED BY 06/12/20 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
De.
NEED BY 061220 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!.docxhallettfaustina
NEED BY 06/12/20 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
Describes statistical significance to pediatric nursing grounded in scholarly literature. Collates utilized references and summarizes key points.
· Statistical significance-
· Key Points
***Need 1 scholarly source
Use the article attached the title is for this presentation:
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE?"
KEYPOINTS: answer theses questions and describe statistical data
· Childhood Obesity- What is their growth/BMI?
· Is there a pathophysiological dilemma such as Binge Eating Disorder (BED)?
· What are the cultural differences and customs to provide client centered quality care?
· How can we observe and assess what beliefs the client has on food choices and psychosocial needs?
· What are their cognitive level/ learning needs?
· What are their educational needs?
· What availability does client have to food and nutrition (economical status)?
· What are some healthy food choices and activity for better living?
· What can we provide as resources to client when there is economical hardships involved?
· What beliefs or morals are ok with you on this topic?
STATISTICAL SIGNIFICANCE:
** use the article attached and another scholarly source of choice if needed
APA FORMAT and intext citation
NEED BY
06/12/20 CST Chicago
, IL
t
ime
. NO
PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
Describes statistical significance to pediatric nursing grounded in scholarly literature. Collates utilized
references and summarizes key points.
·
Statistical significance
-
·
Key
Points
***
Need
1
scholarly source
Use the article attached the title is for this presentation
:
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE?"
K
EYPOI
NTS:
answer the
ses questions and describe stati
s
tical data
·
Childhood Obesity
-
What is their growth/BMI?
·
Is there a pathophysiological dilemma such as Binge Eating Disorder (BED)?
·
What are the
cultural differences and cus
toms to provide client centered quality care?
·
How can we observe and assess what beliefs the client has on food choices and psychosocial
needs?
·
What are their cognitive level/ learning needs?
·
What are their educational needs?
·
What availability does client have to food and nutrition (economical status)?
·
What are some healthy food choices and activity for better living?
·
What can we provide as resources to client when there is economical hardships involved?
·
W
hat
bel
iefs or morals are ok wi
th you on this t
opic?
STATISTIC
AL SIGNIF
ICANCE
:
** use the article attached and
another sch
olarly source o
f choice
if nee
ded
APA FORMAT and intext citation
NEED BY 06/12/20 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
De.
Increasing Fruit and Vegetable Intake andDecreasing Fat and .docxjaggernaoma
Increasing Fruit and Vegetable Intake and
Decreasing Fat and Sugar Intake in Families at
Risk for Childhood Obesity
Leonard H. Epstein, Constance C. Gordy, Hollie A. Raynor, Marlene Beddome, Colleen K. Kilanowski, and
Rocco Paluch
Abstract
EPSTEIN, LEONARD H., CONSTANCE C. GORDY,
HOLLIE A. RAYNOR, MARLENE BEDDOME,
COLLEEN K. KILANOWSKI, AND ROCCO PALUCH.
Increasing fruit and vegetable intake and decreasing fat and
sugar intake in families at risk for childhood obesity.Obes
Res.2001;9:171–178.
Objective:The goal of this study was to evaluate the effect
of a parent-focused behavioral intervention on parent and
child eating changes and on percentage of overweight
changes in families that contain at least one obese parent
and a non-obese child.
Research Methods and Procedures:Families with obese
parents and non-obese children were randomized to
groups in which parents were provided a comprehensive
behavioral weight-control program and were encouraged
to increase fruit and vegetable intake or decrease intake
of high-fat/high-sugar foods. Child materials targeted the
same dietary changes as their parents without caloric
restriction.
Results:Changes over 1 year showed that treatment influ-
enced targeted parent and child fruit and vegetable intake
and high-fat/high-sugar intake, with the Increase Fruit and
Vegetable group also decreasing their consumption of
high-fat/high-sugar foods. Parents in the increased fruit and
vegetable group showed significantly greater decreases in
percentage of overweight than parents in the decreased
high-fat/high-sugar group.
Discussion:These results suggest that focusing on increas-
ing intake of healthy foods may be a useful approach for
nutritional change in obese parents and their children.
Key words: fruits, vegetables, pediatric, prevention
Introduction
The prevalence of obesity in children (1) is increasing.
Although pediatric treatment has been relatively successful,
many treated children also regain weight during follow-up
(2). Given difficulties in changing established eating and
exercise behaviors, research is needed to prevent obesity
during development. Primary prevention may involve mod-
ifying intake and/or increasing expenditure, but the biggest
effect on energy balance will come from modifying intake,
because research suggests that obese and non-obese chil-
dren have similar activity levels (3,4).
Most dietary approaches for obesity treatment or preven-
tion attempt to limit intake of high-fat, low-nutrient dense
foods. This may be perceived as a dietary restriction by
people who find these foods reinforcing. The perceived
restriction can lead to increases in preference for these foods
(5), thereby increasing the probability of relapsing to pre-
vious eating habits when structured interventions are re-
moved. An alternative approach would be to teach children
to increase intake of healthy high-nutrient dense foods, such
as fruits and vegetables, which has been the target of large
public health in.
1· The precise goal of the study or experiment· The populati.docxeugeniadean34240
1
· The precise goal of the study or experiment
· The population
· Your expected sample size
· How you will go about collecting your sample
· Exactly what statistical computations you expect to perform (hypothesis, null hypothesis, alternative hypothesis, type I and II error, significance level, critical value, P-value, etc.
· How you will present your results to the reader
· Itemized expected cost for your study in terms of time and money
Childhood Obesity among Pittsburgh School Students, Ages 6-12 Years
The hypothesis of if schools served healthier food and gave the children more time to eat as well as having more chances to be active, like recess and physical education, then child hood obesity rates would decrease drastically. This study will investigate effects of teaching obese children better habits of eating and exercise and improved habits and self-esteem. The children for the study will be drawn from the general school population (ages 6 to 12). Students (n = 20) will receive a brief intervention regarding nutrition, activity, and snacking. Students will serve as their own control. Each participant will be pre- and post-tested regarding eating behavior, activity, snacking behavior, and levels of self-esteem. The hypothesis will be tested through the application of quantitative analysis (one-way ANOVA) to the data collected
(Dotsch, Kokocinski, Knerr, Rascher, Rascher & Weigel, 2008).
The goal of this proposal is to study the prevalence of obesity among school children 6-12 years old in Pittsburgh Public Schools, and to identify any variation as per age, gender, place of residence, and type of school. Obesity is usually defined as more than 20 percent above ideal weight for a particular height and age ("Obesity,"). This proposal is addressed to meet the needs of children who have become obese due to environmental factors. If we can alter a few key and relatively simple areas in the lives of individuals, reinforce this within the schools and community, and re-evaluate the messages being sent in our culture, American school children will soon see an end to an excessive weight gain.
The results of this survey are important for the development of evidence-based practice guidelines and the overall process will have an impact on the clinical practice, research and dietetic policy.
School children between 6-12 years old will be sampled using stratified random sampling (SRS) with cumulative population proportionate from each school (cluster) of four districts. A total of 20 clusters will be selected by systematic sampling. The clusters spread out geographically by schools, and then the sample starts at a random cluster and then takes every 10th cluster in the list. First, take a separate SRS in each stratum to allow separate conclusions about each stratum. Then, a stratified sample will have a smaller margin of error than an SRS of the same size. Data will be analyzed using Body Mass Index (BMI- CDC) calculator and/or a .
Literature Evaluation TableStudent Name Christiana Bona.Summa.docxcroysierkathey
Literature Evaluation Table
Student Name: Christiana Bona.
Summary of Clinical Issue (200-250 words):
Childhood obesity is one of the problems that affect the United States and other developed economies. Obesity among children and youths is widely recognized as an issue that generates a lot of adverse health impacts. For instance, childhood obesity is a major indicator of future mental and physical health problems. In spite of the highest rates of childhood obesity in the country in the last three decades, obesity has been linked to other more serious health problems such as cardiovascular diseases and diabetes. As nurses and other health professionals continue to grapple with this problem, there are still no clear treatment approaches. Health professionals usually do not have a comprehensive guideline on where to manage the nearly one-third of their populations who present the medical care with obesity that coexists with other medical conditions and problems. Numerous treatment models have been proposed to address this rising public health concern. These approaches often include use of the traditional interventions such as pharmacological interventions. However, overemphasis on one treatment intervention may fail to generate the desired objectives. While the traditional strategies to obesity prevention and management have placed emphasis on medications, wider attention to other dimensions of treatment is necessary. Such treatment interventions may include the multi-tiered or holistic strategies that incorporate both pharmacological and non-pharmacological interventions. For instance, a wider focus should incorporate practices such as assessing the mental health impacts of obesity on the patients. Thus, a public health multi-tiered approach to obesity that emphasizes on promotion, prevention, and individualized interventions are recommended.
PICOT Question: Is the use of multi-tiered approach to the treatment and management of childhood obesity more effective than overreliance on only pharmacological interventions in reducing obesity prevalence rates?
Criteria
Article 1
Article 2
Article 3
APA-Formatted Article Citation with Permalink
Cuda, S. E., & Censani, M. (2018). Pediatric Obesity Algorithm: A Practical Approach to Obesity Diagnosis and Management. Frontiers in pediatrics, 6.
Heerman, W. J., Schludnt, D., Harris, D., Teeters, L., Apple, R., & Barkin, S. L. (2018). Scale-out of a community-based behavioral intervention for childhood obesity: pilot implementation evaluation. BMC public health, 18(1), 498.
Bazyk, S., & Winne, R. (2013). A multi-tiered approach to addressing the mental health issues surrounding obesity in children and youth. Occupational therapy in health care, 27(2), 84-98.
How Does the Article Relate to the PICOT Question?
The article is relevant to the PICOT question because it proposes the use of algorithms and technological systems that have data on all aspects of a child’s obesity prevention and management st ...
Running head CHILDHOOD OBESITY 1CHILDHOOD OBESITY 7.docxsusanschei
Running head: CHILDHOOD OBESITY 1
CHILDHOOD OBESITY 7
Qualitative Research Critique and Ethical Considerations
Qualitative Research Critique and Ethical Considerations
Summary of the Study
The study seeks to evaluate the efficacy of school-based programs in treating and managing overweight and obesity among children. Childhood obesity is increasingly becoming both national and global public health concern that has resulted in increased childhood morbidity and mortality. In particular, childhood obesity has catapulted the increase in health problems such as cardiovascular diseases, diabetes, as well as osteoarthritis later in adulthood (Mahmood et al. 2014). Schools can provide one of the most effective channels through which childhood obesity interventions can be directed. In this respect, policies, procedures, and guidelines have been passed in many nations and states for the implementation of school-based interventions. In the United States, many studies have recommended the utilization of school-based obesity management programs to address the unending crisis of childhood obesity. In light of this concern, this study seeks to investigate the efficacy of school-based interventions in treating and managing childhood obesity. In particular, the study will also assess school methodologies such as incorporation of obesity education into the routine curriculum in minimizing the constantly-increasing cases of obese children population.
Method of Study
The study is also going to use qualitative design in order to examine the perception of children towards school-based obesity management initiatives. Previous studies conducted by Clarke et al. (2015) also sought to investigate the experiences and views of kids who went through school-based obesity management programs. This can help to improve knowledge and understanding of better ways to address the problem of childhood obesity within school settings. In order to provide a comprehensive finding that guides future clinical decision-making, the study will evaluate efficacy of school-based interventions with respect to many key areas. They include cost efficiency of school-based interventions, improvements in physical activities and healthy eating habits following interventions, as well as level of awareness among children on the dangers of childhood obesity and the ways in which it can be averted. Furthermore, effectiveness will be investigated through evaluation of body weight and BMI before and after the introductions of these interventions (Mahmood et al. 2014). Most significantly, cardiovascular fitness and other outcome measures will be investigated. The target population and participants of the study will mainly be school-going children. Both boys and girls with an average age of between 8 and 16 years will be incorporated into the study.
Schools vary in the ways in which they utilize such interventions. For instance, some schools utilize planet health programs that incorpo ...
Does physical-activity-and-sport-practice-lead-to-a-healthier-lifestyle-and-e...Annex Publishers
The prevalence of childhood obesity has been increasing rapidly and there is general consensus that good nutritional practices and physical activity should be encouraged as early as possible in life. The aim of this study was to describe and to compare the current lifestyle and dietary pattern of normal weight (NW) and overweight + obese (OW+OB) male adolescents who are physically active.
Methods: This observational and retrospective study was based on clinical records analysis of male adolescents aged 11-18 years who had undergone a medical evaluation at a Medical Sport Centre (Pavia, Italy) during 2009, and had filled in a self-administered life style questionnaire.
Results: The results showed that out of 1423 clinical records 23.0% of subjects were OW, 5.4% OB and 71.6% NW. We invited all the overweight and obese subjects to participate in the study, 308 of them (75.8%) agreed. Then we randomly enrolled an equivalent number of NW participants (n=308) in the medical evaluation at the sports center with similar characteristics as for socio-economic status, physical activity and age for a whole sample of 616 subjects. We handled them a validated lifestyle questionnaire. The questionnaire analysis was used to compare OW+OB and NW participants, as far as eating habits, sedentary activities and time spent in sports. All the subjects frequently skipped breakfast, did not consume fruit and vegetables daily and had a high soft drinks intake. Inverse correlations were found between weight and physical activity (p=0.01). Sedentary activities were preferred by about 25% and 66 % of the NW and OW+OB groups respectively. The percentage of smokers was similar within the two groups (14%).
Conclusions: Adolescents eating habits are incorrect, despite BMI and sports practice. Sports practice seems contributing to lower spare time physical inactivity, but does not improve eating habits. Public health interventions should focus on the reinforcement of leisure time physical activity, besides nutrition education and behavioral education programs in order to prevent obesity in the adulthood.
Aene project a medium city public students obesity studyCIRINEU COSTA
Identifying undernutrition and obesity on students and propose public policies of health are urgent issues. This paper presents a study with weight and stature from students collected by physical education teachers (PEF) in schools of a city near São Paulo. The PEF collected the data and they were inserted in a program especially developed for each school Department (AENE Project). The datas were analyzed by software and evaluation done based on a World Health Organization (WHO_2007) table, that develops health programs worldwide. The results evaluations were used to raise the students and family, teachers and responsibles for treatment search (when required).
Soraya Ghebleh - Strategies to Reduce Childhood ObesitySoraya Ghebleh
This is a presentation from Soraya Ghebleh that looks at the problem of childhood obesity in America and offers potential policy and strategy solutions.
This modules animation What Is Communication provides background .docxhopeaustin33688
This module's animation What Is Communication? provides background for this assignment.
The six characteristics from which you should choose are:
Involves interdependent individuals
Is inherently rational
Exists on a continuum
Features verbal and nonverbal messages
Exists in varied forms
Varies in effectiveness
Write a 1-page essay that explains 2 of the 6 characteristics of interpersonal communication and illustrate how each one is demonstrated in your communication style. Include at least one quotation from your research. Cite your source in APA format.
.
▪Nursing Theory PowerPoint Presentation.This is a group project .docxhopeaustin33688
▪
Nursing Theory PowerPoint Presentation.
This is a group project this is my part…
Lydia Hall The 3 Cs Nursing Theory. (im doing the CORE, and the strengths and weakness of the whole theory)
WIKI Project Guideline:
1
4 to 6 slides plus a reference slide on the nursing theory
(THE CORE & the strengths and the weakness)
2 responsible to
create 2-3 voice-over PPT (FEMALE VOICE)
slides on their designated topic area.
3Please note that
APA
format is required within the PowerPoint presentation. Reference slides are required at the end of the presentation.
This assignment will be graded according to the following rubric:
Criteria
Points
WIKI content 8
APA in-text citation and reference page 4
Multimedia Inclusion 3
Total
15
.
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Running head LITERATURE REVIEW 1LITERATURE REVIEW 5.docxcowinhelen
Running head: LITERATURE REVIEW 1
LITERATURE REVIEW 5
Literature Review
Name:
Institution:
Literature Review (Childhood Obesity)
Childhood Obesity describes attainments of weight beyond the normal body mass index ration leading to the vulnerability in lines. In the study, the use of article will facilitate the process. As noted, the researcher of the material sought to evaluate the factors that contribute to obesity in children. Their study focused on dieting and physical exercise as the primary factors that contribute to obesity. The researchers commenced the process by identifying the research question, proceeded with instruments then selected the design before engaging the target population to validate the research hypothesis. The target group for the study comprised of children aged below 12 years. They included children from a different racial background. Both boys and girls featured in the study. The researcher hypothesized the cause of obesity with the motive of encouraging the adaptation of intervention programs. The study prioritized preventive measures with the intent of decreasing cases of obesity in children in less than six months.
The literature for study includes article 1, 2, 3 and 4. Article 5, 6, 7 and 8 also featured in the study. The research sought to evaluate the prevailing trends concerning the wellness of the children using a collection of questions. The first article by Bleich, Segal, Wu, and Wilson& Wang sought to evaluate the role of community-based prevention. The second article by Tester et al examined the characteristics of the condition in children aged between 2 and 5. The third article by Cunningham, Kramer, & Narayan quantified the prevalence of the condition. Arthur, Scharf, and DeBoer’s fourth sought to evaluate the role of food insecurity in the contraction of obesity. The fifth and sixth Fetter et al and Lydecke, Riley, & Grilo examined the role of physical activity and parenting subsequently. The exploration of the implication of the limitation of the dietary behavior of the micro levels of the condition and parents understanding on the condition featured in the seventh and eight articles composed by Marcum, et al, and Vollmer respectively.
The sample population for the study in the first article comprised of the young population in homes school and care setting. The second article engaged children aged between 2 and 5 years. The third article engaged 7738 participants comprising of learners in kindergarten. The group in the early childhood stage featured in the fourth article as the sample population for the study seeking to investigate cases of obesity. The sample differed from the group engaged in the fifth and sixth article. The category interviewed comprised of the parents of the youth and pre-adolescents, the seventh and eight articles engaged the mothers of the children and the fathers averaging 35 years of white origin.
The limitation of the first article is that the resear ...
NEED BY 061220 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!.docxTanaMaeskm
NEED BY 06/12/20 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
Describes statistical significance to pediatric nursing grounded in scholarly literature. Collates utilized references and summarizes key points.
· Statistical significance-
· Key Points
***Need 1 scholarly source
Use the article attached the title is for this presentation:
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE?"
KEYPOINTS: answer theses questions and describe statistical data
· Childhood Obesity- What is their growth/BMI?
· Is there a pathophysiological dilemma such as Binge Eating Disorder (BED)?
· What are the cultural differences and customs to provide client centered quality care?
· How can we observe and assess what beliefs the client has on food choices and psychosocial needs?
· What are their cognitive level/ learning needs?
· What are their educational needs?
· What availability does client have to food and nutrition (economical status)?
· What are some healthy food choices and activity for better living?
· What can we provide as resources to client when there is economical hardships involved?
· What beliefs or morals are ok with you on this topic?
STATISTICAL SIGNIFICANCE:
** use the article attached and another scholarly source of choice if needed
APA FORMAT and intext citation
NEED BY
06/12/20 CST Chicago
, IL
t
ime
. NO
PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
Describes statistical significance to pediatric nursing grounded in scholarly literature. Collates utilized
references and summarizes key points.
·
Statistical significance
-
·
Key
Points
***
Need
1
scholarly source
Use the article attached the title is for this presentation
:
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE?"
K
EYPOI
NTS:
answer the
ses questions and describe stati
s
tical data
·
Childhood Obesity
-
What is their growth/BMI?
·
Is there a pathophysiological dilemma such as Binge Eating Disorder (BED)?
·
What are the
cultural differences and cus
toms to provide client centered quality care?
·
How can we observe and assess what beliefs the client has on food choices and psychosocial
needs?
·
What are their cognitive level/ learning needs?
·
What are their educational needs?
·
What availability does client have to food and nutrition (economical status)?
·
What are some healthy food choices and activity for better living?
·
What can we provide as resources to client when there is economical hardships involved?
·
W
hat
bel
iefs or morals are ok wi
th you on this t
opic?
STATISTIC
AL SIGNIF
ICANCE
:
** use the article attached and
another sch
olarly source o
f choice
if nee
ded
APA FORMAT and intext citation
NEED BY 06/12/20 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
De.
NEED BY 061220 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!.docxhallettfaustina
NEED BY 06/12/20 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
Describes statistical significance to pediatric nursing grounded in scholarly literature. Collates utilized references and summarizes key points.
· Statistical significance-
· Key Points
***Need 1 scholarly source
Use the article attached the title is for this presentation:
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE?"
KEYPOINTS: answer theses questions and describe statistical data
· Childhood Obesity- What is their growth/BMI?
· Is there a pathophysiological dilemma such as Binge Eating Disorder (BED)?
· What are the cultural differences and customs to provide client centered quality care?
· How can we observe and assess what beliefs the client has on food choices and psychosocial needs?
· What are their cognitive level/ learning needs?
· What are their educational needs?
· What availability does client have to food and nutrition (economical status)?
· What are some healthy food choices and activity for better living?
· What can we provide as resources to client when there is economical hardships involved?
· What beliefs or morals are ok with you on this topic?
STATISTICAL SIGNIFICANCE:
** use the article attached and another scholarly source of choice if needed
APA FORMAT and intext citation
NEED BY
06/12/20 CST Chicago
, IL
t
ime
. NO
PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
Describes statistical significance to pediatric nursing grounded in scholarly literature. Collates utilized
references and summarizes key points.
·
Statistical significance
-
·
Key
Points
***
Need
1
scholarly source
Use the article attached the title is for this presentation
:
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE?"
K
EYPOI
NTS:
answer the
ses questions and describe stati
s
tical data
·
Childhood Obesity
-
What is their growth/BMI?
·
Is there a pathophysiological dilemma such as Binge Eating Disorder (BED)?
·
What are the
cultural differences and cus
toms to provide client centered quality care?
·
How can we observe and assess what beliefs the client has on food choices and psychosocial
needs?
·
What are their cognitive level/ learning needs?
·
What are their educational needs?
·
What availability does client have to food and nutrition (economical status)?
·
What are some healthy food choices and activity for better living?
·
What can we provide as resources to client when there is economical hardships involved?
·
W
hat
bel
iefs or morals are ok wi
th you on this t
opic?
STATISTIC
AL SIGNIF
ICANCE
:
** use the article attached and
another sch
olarly source o
f choice
if nee
ded
APA FORMAT and intext citation
NEED BY 06/12/20 CST Chicago, IL time . NO PLAGIARISM ALLOWED!!
SHOULD PARENTS DETERMINE FAMILY EATING HABITS WHEN THE CHILD IS OBESE
De.
Increasing Fruit and Vegetable Intake andDecreasing Fat and .docxjaggernaoma
Increasing Fruit and Vegetable Intake and
Decreasing Fat and Sugar Intake in Families at
Risk for Childhood Obesity
Leonard H. Epstein, Constance C. Gordy, Hollie A. Raynor, Marlene Beddome, Colleen K. Kilanowski, and
Rocco Paluch
Abstract
EPSTEIN, LEONARD H., CONSTANCE C. GORDY,
HOLLIE A. RAYNOR, MARLENE BEDDOME,
COLLEEN K. KILANOWSKI, AND ROCCO PALUCH.
Increasing fruit and vegetable intake and decreasing fat and
sugar intake in families at risk for childhood obesity.Obes
Res.2001;9:171–178.
Objective:The goal of this study was to evaluate the effect
of a parent-focused behavioral intervention on parent and
child eating changes and on percentage of overweight
changes in families that contain at least one obese parent
and a non-obese child.
Research Methods and Procedures:Families with obese
parents and non-obese children were randomized to
groups in which parents were provided a comprehensive
behavioral weight-control program and were encouraged
to increase fruit and vegetable intake or decrease intake
of high-fat/high-sugar foods. Child materials targeted the
same dietary changes as their parents without caloric
restriction.
Results:Changes over 1 year showed that treatment influ-
enced targeted parent and child fruit and vegetable intake
and high-fat/high-sugar intake, with the Increase Fruit and
Vegetable group also decreasing their consumption of
high-fat/high-sugar foods. Parents in the increased fruit and
vegetable group showed significantly greater decreases in
percentage of overweight than parents in the decreased
high-fat/high-sugar group.
Discussion:These results suggest that focusing on increas-
ing intake of healthy foods may be a useful approach for
nutritional change in obese parents and their children.
Key words: fruits, vegetables, pediatric, prevention
Introduction
The prevalence of obesity in children (1) is increasing.
Although pediatric treatment has been relatively successful,
many treated children also regain weight during follow-up
(2). Given difficulties in changing established eating and
exercise behaviors, research is needed to prevent obesity
during development. Primary prevention may involve mod-
ifying intake and/or increasing expenditure, but the biggest
effect on energy balance will come from modifying intake,
because research suggests that obese and non-obese chil-
dren have similar activity levels (3,4).
Most dietary approaches for obesity treatment or preven-
tion attempt to limit intake of high-fat, low-nutrient dense
foods. This may be perceived as a dietary restriction by
people who find these foods reinforcing. The perceived
restriction can lead to increases in preference for these foods
(5), thereby increasing the probability of relapsing to pre-
vious eating habits when structured interventions are re-
moved. An alternative approach would be to teach children
to increase intake of healthy high-nutrient dense foods, such
as fruits and vegetables, which has been the target of large
public health in.
1· The precise goal of the study or experiment· The populati.docxeugeniadean34240
1
· The precise goal of the study or experiment
· The population
· Your expected sample size
· How you will go about collecting your sample
· Exactly what statistical computations you expect to perform (hypothesis, null hypothesis, alternative hypothesis, type I and II error, significance level, critical value, P-value, etc.
· How you will present your results to the reader
· Itemized expected cost for your study in terms of time and money
Childhood Obesity among Pittsburgh School Students, Ages 6-12 Years
The hypothesis of if schools served healthier food and gave the children more time to eat as well as having more chances to be active, like recess and physical education, then child hood obesity rates would decrease drastically. This study will investigate effects of teaching obese children better habits of eating and exercise and improved habits and self-esteem. The children for the study will be drawn from the general school population (ages 6 to 12). Students (n = 20) will receive a brief intervention regarding nutrition, activity, and snacking. Students will serve as their own control. Each participant will be pre- and post-tested regarding eating behavior, activity, snacking behavior, and levels of self-esteem. The hypothesis will be tested through the application of quantitative analysis (one-way ANOVA) to the data collected
(Dotsch, Kokocinski, Knerr, Rascher, Rascher & Weigel, 2008).
The goal of this proposal is to study the prevalence of obesity among school children 6-12 years old in Pittsburgh Public Schools, and to identify any variation as per age, gender, place of residence, and type of school. Obesity is usually defined as more than 20 percent above ideal weight for a particular height and age ("Obesity,"). This proposal is addressed to meet the needs of children who have become obese due to environmental factors. If we can alter a few key and relatively simple areas in the lives of individuals, reinforce this within the schools and community, and re-evaluate the messages being sent in our culture, American school children will soon see an end to an excessive weight gain.
The results of this survey are important for the development of evidence-based practice guidelines and the overall process will have an impact on the clinical practice, research and dietetic policy.
School children between 6-12 years old will be sampled using stratified random sampling (SRS) with cumulative population proportionate from each school (cluster) of four districts. A total of 20 clusters will be selected by systematic sampling. The clusters spread out geographically by schools, and then the sample starts at a random cluster and then takes every 10th cluster in the list. First, take a separate SRS in each stratum to allow separate conclusions about each stratum. Then, a stratified sample will have a smaller margin of error than an SRS of the same size. Data will be analyzed using Body Mass Index (BMI- CDC) calculator and/or a .
Literature Evaluation TableStudent Name Christiana Bona.Summa.docxcroysierkathey
Literature Evaluation Table
Student Name: Christiana Bona.
Summary of Clinical Issue (200-250 words):
Childhood obesity is one of the problems that affect the United States and other developed economies. Obesity among children and youths is widely recognized as an issue that generates a lot of adverse health impacts. For instance, childhood obesity is a major indicator of future mental and physical health problems. In spite of the highest rates of childhood obesity in the country in the last three decades, obesity has been linked to other more serious health problems such as cardiovascular diseases and diabetes. As nurses and other health professionals continue to grapple with this problem, there are still no clear treatment approaches. Health professionals usually do not have a comprehensive guideline on where to manage the nearly one-third of their populations who present the medical care with obesity that coexists with other medical conditions and problems. Numerous treatment models have been proposed to address this rising public health concern. These approaches often include use of the traditional interventions such as pharmacological interventions. However, overemphasis on one treatment intervention may fail to generate the desired objectives. While the traditional strategies to obesity prevention and management have placed emphasis on medications, wider attention to other dimensions of treatment is necessary. Such treatment interventions may include the multi-tiered or holistic strategies that incorporate both pharmacological and non-pharmacological interventions. For instance, a wider focus should incorporate practices such as assessing the mental health impacts of obesity on the patients. Thus, a public health multi-tiered approach to obesity that emphasizes on promotion, prevention, and individualized interventions are recommended.
PICOT Question: Is the use of multi-tiered approach to the treatment and management of childhood obesity more effective than overreliance on only pharmacological interventions in reducing obesity prevalence rates?
Criteria
Article 1
Article 2
Article 3
APA-Formatted Article Citation with Permalink
Cuda, S. E., & Censani, M. (2018). Pediatric Obesity Algorithm: A Practical Approach to Obesity Diagnosis and Management. Frontiers in pediatrics, 6.
Heerman, W. J., Schludnt, D., Harris, D., Teeters, L., Apple, R., & Barkin, S. L. (2018). Scale-out of a community-based behavioral intervention for childhood obesity: pilot implementation evaluation. BMC public health, 18(1), 498.
Bazyk, S., & Winne, R. (2013). A multi-tiered approach to addressing the mental health issues surrounding obesity in children and youth. Occupational therapy in health care, 27(2), 84-98.
How Does the Article Relate to the PICOT Question?
The article is relevant to the PICOT question because it proposes the use of algorithms and technological systems that have data on all aspects of a child’s obesity prevention and management st ...
Running head CHILDHOOD OBESITY 1CHILDHOOD OBESITY 7.docxsusanschei
Running head: CHILDHOOD OBESITY 1
CHILDHOOD OBESITY 7
Qualitative Research Critique and Ethical Considerations
Qualitative Research Critique and Ethical Considerations
Summary of the Study
The study seeks to evaluate the efficacy of school-based programs in treating and managing overweight and obesity among children. Childhood obesity is increasingly becoming both national and global public health concern that has resulted in increased childhood morbidity and mortality. In particular, childhood obesity has catapulted the increase in health problems such as cardiovascular diseases, diabetes, as well as osteoarthritis later in adulthood (Mahmood et al. 2014). Schools can provide one of the most effective channels through which childhood obesity interventions can be directed. In this respect, policies, procedures, and guidelines have been passed in many nations and states for the implementation of school-based interventions. In the United States, many studies have recommended the utilization of school-based obesity management programs to address the unending crisis of childhood obesity. In light of this concern, this study seeks to investigate the efficacy of school-based interventions in treating and managing childhood obesity. In particular, the study will also assess school methodologies such as incorporation of obesity education into the routine curriculum in minimizing the constantly-increasing cases of obese children population.
Method of Study
The study is also going to use qualitative design in order to examine the perception of children towards school-based obesity management initiatives. Previous studies conducted by Clarke et al. (2015) also sought to investigate the experiences and views of kids who went through school-based obesity management programs. This can help to improve knowledge and understanding of better ways to address the problem of childhood obesity within school settings. In order to provide a comprehensive finding that guides future clinical decision-making, the study will evaluate efficacy of school-based interventions with respect to many key areas. They include cost efficiency of school-based interventions, improvements in physical activities and healthy eating habits following interventions, as well as level of awareness among children on the dangers of childhood obesity and the ways in which it can be averted. Furthermore, effectiveness will be investigated through evaluation of body weight and BMI before and after the introductions of these interventions (Mahmood et al. 2014). Most significantly, cardiovascular fitness and other outcome measures will be investigated. The target population and participants of the study will mainly be school-going children. Both boys and girls with an average age of between 8 and 16 years will be incorporated into the study.
Schools vary in the ways in which they utilize such interventions. For instance, some schools utilize planet health programs that incorpo ...
Does physical-activity-and-sport-practice-lead-to-a-healthier-lifestyle-and-e...Annex Publishers
The prevalence of childhood obesity has been increasing rapidly and there is general consensus that good nutritional practices and physical activity should be encouraged as early as possible in life. The aim of this study was to describe and to compare the current lifestyle and dietary pattern of normal weight (NW) and overweight + obese (OW+OB) male adolescents who are physically active.
Methods: This observational and retrospective study was based on clinical records analysis of male adolescents aged 11-18 years who had undergone a medical evaluation at a Medical Sport Centre (Pavia, Italy) during 2009, and had filled in a self-administered life style questionnaire.
Results: The results showed that out of 1423 clinical records 23.0% of subjects were OW, 5.4% OB and 71.6% NW. We invited all the overweight and obese subjects to participate in the study, 308 of them (75.8%) agreed. Then we randomly enrolled an equivalent number of NW participants (n=308) in the medical evaluation at the sports center with similar characteristics as for socio-economic status, physical activity and age for a whole sample of 616 subjects. We handled them a validated lifestyle questionnaire. The questionnaire analysis was used to compare OW+OB and NW participants, as far as eating habits, sedentary activities and time spent in sports. All the subjects frequently skipped breakfast, did not consume fruit and vegetables daily and had a high soft drinks intake. Inverse correlations were found between weight and physical activity (p=0.01). Sedentary activities were preferred by about 25% and 66 % of the NW and OW+OB groups respectively. The percentage of smokers was similar within the two groups (14%).
Conclusions: Adolescents eating habits are incorrect, despite BMI and sports practice. Sports practice seems contributing to lower spare time physical inactivity, but does not improve eating habits. Public health interventions should focus on the reinforcement of leisure time physical activity, besides nutrition education and behavioral education programs in order to prevent obesity in the adulthood.
Aene project a medium city public students obesity studyCIRINEU COSTA
Identifying undernutrition and obesity on students and propose public policies of health are urgent issues. This paper presents a study with weight and stature from students collected by physical education teachers (PEF) in schools of a city near São Paulo. The PEF collected the data and they were inserted in a program especially developed for each school Department (AENE Project). The datas were analyzed by software and evaluation done based on a World Health Organization (WHO_2007) table, that develops health programs worldwide. The results evaluations were used to raise the students and family, teachers and responsibles for treatment search (when required).
Soraya Ghebleh - Strategies to Reduce Childhood ObesitySoraya Ghebleh
This is a presentation from Soraya Ghebleh that looks at the problem of childhood obesity in America and offers potential policy and strategy solutions.
This modules animation What Is Communication provides background .docxhopeaustin33688
This module's animation What Is Communication? provides background for this assignment.
The six characteristics from which you should choose are:
Involves interdependent individuals
Is inherently rational
Exists on a continuum
Features verbal and nonverbal messages
Exists in varied forms
Varies in effectiveness
Write a 1-page essay that explains 2 of the 6 characteristics of interpersonal communication and illustrate how each one is demonstrated in your communication style. Include at least one quotation from your research. Cite your source in APA format.
.
▪Nursing Theory PowerPoint Presentation.This is a group project .docxhopeaustin33688
▪
Nursing Theory PowerPoint Presentation.
This is a group project this is my part…
Lydia Hall The 3 Cs Nursing Theory. (im doing the CORE, and the strengths and weakness of the whole theory)
WIKI Project Guideline:
1
4 to 6 slides plus a reference slide on the nursing theory
(THE CORE & the strengths and the weakness)
2 responsible to
create 2-3 voice-over PPT (FEMALE VOICE)
slides on their designated topic area.
3Please note that
APA
format is required within the PowerPoint presentation. Reference slides are required at the end of the presentation.
This assignment will be graded according to the following rubric:
Criteria
Points
WIKI content 8
APA in-text citation and reference page 4
Multimedia Inclusion 3
Total
15
.
••You are required to write a story; explaining and analyzing .docxhopeaustin33688
•
•
You are required to write a story;
explaining and analyzing
how a certain independent variable ( at the individual, group or organization levels) affects a
dependent
variable (
behaviour
or attitude),
•
You will freely select your story from “ life” : from college, home, neighborhood, a book , a video/ movie, TV…etc. as long as the
story has two clear dependent and independent variables.
•
You will finish with
a conclusion
that lists
both variables
and their
relationship (cause and effect).
.
•Required to read American Mashup A Popular Culture Reader. Ed. A.docxhopeaustin33688
•Required to read American Mashup: A Popular Culture Reader. Ed. Aaron Michael Morales. Boston: Pearson, 2012.
After reading Richard Willig’s “ ‘CSI Effect’ Has Juries Wanting More Evidence” in
American Mashup
on pages 204-210. Consider the types of sources Willig uses to support his main claims. please present at least four (4) specific examples of Willig’s sources. For each source, please identify what that person’s professional ability is and explain how that person’s position of authority helps Willig build his own credibility with readers.
.
• ntercultural Activity Presentation Final SubmissionResourc.docxhopeaustin33688
•
ntercultural
Activity Presentation Final Submission
Resources
•
Intercultural Activity Presentation Final Submission Scoring Guide
.
•
Writing Feedback Tool
.
•
APA Style and Format
.
•
Using Adobe Connect
.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
•
Competency 3:
Demonstrate knowledge, skills, and attitudes to increase intercultural competence.
•
Compare differing cultures.
•
Discuss the potential impact cultural differences have on communication efforts.
•
Competency 4:
Analyze how nonverbal communication (body language) influences intercultural communication.
•
Analyze how nonverbal communication affects intercultural communication.
•
Competency 5:
Communicate effectively in a variety of formats and contexts.
•
Integrate cross-cultural experiences with course material.
•
Write coherently to support a central idea in appropriate format with correct grammar, usage, and mechanics.
Instructions
This is the second part of your course project. For this assignment, create a 5–7 minute Adobe Connect video presentation with a visual component (PowerPoint) in which you narrate and describe an intercultural activity and experience. Complete the following for your presentation:
•
Engage in an intercultural activity or activities with a culture other than your own. You may focus on the same culture you investigated for your Unit 9 paper or choose one that is new to you; however, you must choose a different culture than the one from whom you interviewed someone in Unit 5. Some suggestions for activities to engage in include:
•
Eating at an ethnic restaurant.
•
Visiting a courthouse, jail, military installation, school, retirement home, and other ethnically-diverse institution.
•
Visiting a part of town that is culturally different.
•
Visiting or attending a service of another world religion.
•
Attending a celebration or an ethnically diverse craft fair.
•
Going to a shop that is associated with a particular ethnic group.
•
Visiting a school that teaches ESL (English as a Second Language) or ELL (English Language Learners).
•
Visiting an international student organization at a college or university.
•
Visiting or socializing with people from other cultures.
•
To add perspective and context to your presentation, gather resources such as informal interviews with people from the respective culture, corresponding text readings and articles, Web sites, and media presentations.
•
In your presentation, specifically address the following, using examples and illustrations from your intercultural experience(s) and the resources you collected:
•
Compare the culture you engaged in with your own.
•
Discuss the potential impact cultural differences have on communication.
•
Analyze how nonverbal communication affects intercultural communication.
•
Summarize your thoughts, questions, and viewpoints regarding your experience.
•
.
•Read Chapter 15 from your textbookEthical Controversy Ident.docxhopeaustin33688
•Read Chapter 15 from your textbook
Ethical Controversy
Identify a current ethical controversy that you want to learn more about in business, media, technology, medicine, or bioethics. Write a
three-page analysis
on the major sides in the controversy. In your analysis paper, you need to:
Define the issue and include the following details:
People involved
Field (business, media, technology, medicine, or bioethics)
Purpose
Time period
Discuss the major positions being taken in the debate.
Conclude with your own reflections and opinions on the subject.
Submission Requirements:
Write the paper in APA format including introduction, body, and conclusion.
Add the following sections in APA format:
Cover Page
Header
Page Numbers
References Page
Use 12-point Arial font and double space.
.
· ResearchWorks Cited Page (minimum of 5 reputable resources.docxhopeaustin33688
·
Research/Works Cited Page (minimum of 5 reputable resources And 5 Pages or 1400 words )
:
I need someone to write my research paper with minimum of 5 reputable reseources and 5 pages or 1400 words . And the the research topic is
Gay Issues.
Research
Clearly defined academic research
:
Did your display/project provide Theory, Data, Studies, Organizations,
Solution
s, Forms of Activism and/or Awareness?
Organization
is your information presented in a way that is well organized and coherent? When you verbally share what you know do you demonstrate an educated knowledge of the topic?
Time
did you put in time for planning, developing your project and to educate the class?
On the attachment I have attached my Presentation about
Gay Issues and My old work of writing so that you can write with same level of writing.
Gay Issues
.
‘The Other Side of Immigration’ Questions1. What does one spea.docxhopeaustin33688
‘
The Other Side of Immigration’ Questions
1. What does one speaker in the film mean by migration is not the problem? Do most Mexican immigrants want to stay in the US?
2. Describe how undocumented immigrants create a fantasy for those Mexicans planning to immigrate.
3. How does NAFTA (North American Free Trade Agreement) play a part in the rural Mexicans’ inability to make a living? Be specific.
4. What is the significance of government not providing subsidies or revealing funding opportunities to the agricultural/pastoral communities?
5. Name two solutions to reducing undocumented immigration that were mentioned in the film. How would they work?
From the movie '
The Other Side of Immigration'
.
•Topic What is an ethical leader and how do ethical leaders differ .docxhopeaustin33688
•Topic: What is an ethical leader and how do ethical leaders differ from other leaders? What are the factors that promote or hinder the development of ethical leadership in organisations (e.g., personal characteristics of leaders and what characteristics of a leader‘s environment)?
• 2500 words (+/- 10%) in essay format
•Requirements: MINIMUM of 8 peer reviewed academic journal articles
–Text book or reference books are additional references
–General websites/blogs , newpapers, magazines are not acceptable references
•Submission method: Upload a soft copy of a Microsoft Word Document ( .doc or .docx format) to Turnitin on Moodle
•Correct Harvard Anglia referencing is important
.
·Term Paper International TerrorismDue Week 10 and worth .docxhopeaustin33688
·
Term Paper: International Terrorism
Due Week 10 and worth 200 points
Choose an international terrorist group from the following list, and use the Internet or Strayer databases to research the origin, purpose, and effects on the U.S. or targeted countries.
·
Hezbollah
·
HAMAS
·
Al Qaeda (AQ)
·
Al-Shabaab
·
Haqqani Network (HQN)
Write a ten to fifteen (10-15) page paper in which you:
6.
Provide a brief description of the group, and summarize its origins.
7.
Explain the group’s major motivation(s) (beliefs or causes), and / or its justification for engaging in terrorism.
8.
Describe the group’s major sources of both financial and non-financial support.
9.
Evaluate the importance of the group’s use of media to aid in its terrorist activities. Indicate, at a minimum, the group’s purpose for using the media, the image being portrayed, and the preferred methods of communication.
10.
Determine whether or not the group has a legitimate complaint or demand. Defend your response.
11.
Determine whether or not the group and its activities are of importance to the U.S., and explain the key reasons that they are or are not significant.
12.
Analyze the response of the U.S. to the group or its activities, regardless of whether or not either the group or its activities directly threaten or target the U.S. Determine whether or not that response has been effective. Support your answer with examples of such effectiveness—or the lack thereof.
13.
Suggest the major changes you would make geared toward increasing the efficiency of the U.S.’s response to the group. Justify your response.
14.
Use at least five (5) quality resources in this assignment
And
·
Assignment 5: Senior Seminar Project
Due Week 10 and worth 200 points
In Week 1, you chose a topic area and problem or challenge within that area. Throughout this course, you have researched the dynamics of the problem. The final piece of your project is to develop a viable solution that considers resources, policy, stakeholders, organizational readiness, administrative structures and other internal and external factors, as applicable. Using the papers you have written throughout this course, consolidate your findings into a succinct project.
Write a ten (10) page paper that as a minimum, your project should include:
1.
Identify the topical area (e.g., local police department, community jail, border patrol)
2.
Define a problem or challenge within your topical area that you understand in some depth or have an interest in (examples include high crime rate, poor morale, high levels of violence or recidivism, high number of civilian complaints of harassment, inadequate equipment). Outline the context of the problem or challenge, including the history and any policy decisions that have contributed to the situation.
3.
Describe how internal or external stakeholders have influenced the situation in a positive or negative way. How will you consider stakeholders in your so.
•Prepare a 4-5 page draft Code of Ethics paper sharing the following.docxhopeaustin33688
•Prepare a 4-5 page draft Code of Ethics paper sharing the following:
1) your world view; how you see good and bad, right and wrong, and how you respond to issues. Examine human resources management and
2) share your organization’s core values or principles.
Comment
3) on the validity of those values (are they consistent?).
4) How does everything you shared (#1, 2, 3) impact HR decisions in the workplace? Comment on how you see truth?
Is there such a thing as absolute truth? If so, what is it?
I want her on Wednesday morning at 10
.
·Sketch the context for, define, and tell the significanceafter.docxhopeaustin33688
·
Sketch the context for, define, and tell the significance/after-effect of each, in terms of late-19th & early-20th-century American history & culture: from Sinclair book (The Jungle)
200 word:
1-
1-
National Labor Relations Act (1935) & Fair Labor Standards Act (1938)
·
give the context for, define, and tell the significance/after-effect of each of the following, in terms of 20th-century US culture/history: from Englehardt book (The End of Victory Culture)
200 word:
1-1-
anti-war protests (1967-71) and the "counter-culture"
2-
2-
Vietnam Veterans Memorial (dedicated 1982) [not covered in book; see
http://virtualwall.org/
]
3-
3-
"Authorization of Use of Military Force against Terrorists" Resolution (Sept. 14, 2001)
·
Essays : 250 to 300 word please
choose one of these as you like:
1.
Why was Socialism considered a "radical" ideology and why didn't it flourish in early 20th century America?
2.
In what ways was the Progressive Era (1906-20) truly "progressive" or not; and the "New Deal" (1933-38) really "new" or not, especially in regards to the health, safety and daily lives of U.S. workers and consumers?
.
• Each thread is 650 words• Each thread and reply references at le.docxhopeaustin33688
• Each thread is 650 words
• Each thread and reply references at least 3 peer-reviewed sources and 1 biblical integration.
• All sources are cited in current APA format.
• Proper spelling and grammar are used.
• Sentences are complete, clear, and concise.
***Pepsi Launched a new global Branding campaign based on the cocept of live in the moment called "Live For Now." It did extensive research prior to the campaign's lauch. What research should be done to determine if the campaign is resonating with worldwide audiences?***
.
ØFind a Food borne epidemicIllness that occurred in the U.S. in.docxhopeaustin33688
Ø
Find a Food borne epidemic/Illness that occurred in the U.S. in the last 5 years
Ø
Describe what caused it, how it happened, and how it could have been prevented
Ø
What steps were taken to rectify the situation, both short term and long term
1-2 pages
.
Organizational BehaviorDisney Animation - John LasseterThe case focu.docxhopeaustin33688
Organizational BehaviorDisney Animation - John LasseterThe case focuses on John Lasseter, who currently is the creative head of Disney Animation Studios and Pixar Animation Studios, both of which are owned by The Walt Disney Company. The case chronicles Lasseter’s interests in animation from a young age, the relationship he developed with the Disney organization, his developing interest in computer-animation and consequent demise at Disney Studios, his subsequent award-winning success with computer animation at Pixar Studios, and his recent ascension to creative head of Disney’s Animation Studio as part of the Pixar-Disney merger.The case provides a marvelous illustration of the many types of interpersonal power ¾ reward, coercive, legitimate, referent, and expert that exist within an organization. The case also shows how power can be used to promote the well-being of the organization and its members or to benefit specific people’s interests at the expense of others’ interests. Herein, the two faces of power positive and negative come into play. Another linkage between the chapter material and the case occurs in the form of concerns about the ethical versus unethical use of power. Finally, the case can be used to explore the concepts of organizational politics and political behavior in organizations. Organizational politics often has a negative connotation, and some of the case facts lend themselves to reinforcing this negative connotation.Power and Politics in the Fall and Rise of John LasseterJohn Lasseter grew up in a family heavily involved in artistic expression. Lasseter was drawn to cartoons as a youngster. As a freshman in high school he read a book entitled The Art of Animation. The book, about the making of the Disney animated film Sleeping Beauty, proved to be a revelation for Lasseter. He discovered that people could earn a living by developing cartoons. He started writing letters to The Walt Disney Company Studios regarding his interest in creating cartoons. Studio representatives, who corresponded with Lasseter many times, told him to get a great art education, after which they would teach him animation.When Disney started a Character Animation Program at the California Institute of Arts film school, Lasseter enrolled in the program after encouragement from the studio. Classes were taught by extremely talented Disney animators who also shared stories about working with Walt Disney himself. During summer breaks, jobs at Disneyland further fueled Lasseter’s passion for working as an animator for Disney Studios. Full of excitement, Lasseter joined the Disney animation staff in 1979 after graduation. However, he soon met with disappointment.According to Lasseter, “[t]he animation studio wasn’t being run by these great Disney artists like our teachers at Cal Arts, but by lesser artists and businesspeople who rose through attrition as the grand old men retired.” Lasseter was told, “[y]ou put in your time for 20 years and do what you’r.
Organizational Behavior Case Study on LeadershipName Tan Yee .docxhopeaustin33688
Organizational Behavior Case Study on Leadership
Name: Tan Yee Li Fiona
Student ID: S3447594
Course: RMIT Business (Management)
Leadership, ethics and organizational failure in a post-colonial context: a case study of genocide in Rwanda.
Introduction
Groups, teams and states are major characteristics of organizational life. It is believed that majority of the organization’s practices need a lot of coordination through working as a team and a group.The leadership of an organization is important in terms of the development of the goals and objectives. Leaders within an organization are responsible for developing the goals and objectives of the organization. In most cases, the success of an organization is usually attributed to the leaders of the organization. The genocide in Rwanda was instigated by the hostility between the Hutu and Tutsi as a result of polarization of the two ethnic groups by the colonial era. The colonization process favored one group over the other. It is believed that the leadership of Rwanda at the time played a major role. Leadership in every country plays a major role in the unity of the nation and in fostering peace and co-existence between different ethnic groups. Therefore the leadership of Rwanda at the time failed to quell the existence of animosity between the Hutu and the Tutsi leading to the experience of genocide that led to mass killings. The paper aims at discussing leadership, ethics and organizational failure in a post-colonial context with a case study of genocide in Rwanda. Main emphasis is laid on organizational failure that instigated the genocide and in particular the correlation between the key leaders and geo-political relations (Scott, 1998).
Leadership traits and concepts
Leadership is considered as the ability to influence the followers towards the achievement of set goals and objectives. Leadership is closely related to management which is aimed at ensuring compliance from the organizational members. The trait theory of leadership is important in terms of defining leadership. The characteristics of the leader can be used for the determination of their leadership styles. According to the behavioral theories of leadership, the specific behaviors of the leaders differentiate the leaders from the non leaders. According to the traits theory of leadership, social, physical, personality or intellectual traits can be used for the purpose of differentiating the leaders from the non leaders. According to the theory, the leader is also supposed to be qualified and open. The contingency theory on the other hand analyzes the environment in which the leader operates. Situational leadership theory examines the ability of the followers to readily accept the instructions of the leaders. There are also various styles of leadership and it plays an important role in determining the potential of the leaders. The charismatic leaders usually portray unconventional behaviors and usually understand. On the other.
ORGANIZATIONAL ASSESSMENT WORKSHEET
Organizational Profile
This category is a snapshot of the organization, the key influences that affect how it operates, and the key challenges that it faces.
- Briefly describe the organization, including its services; its size; its geographic community; its key patient or customer groups; the number of patients it services; and its current facilities, equipment, and technology.
- Briefly describe the organization’s key challenges
Leadership
This category examines how the organizational leaders address values, directions, and performance expectations as well as how focused they are on customers, stakeholders, empowerment, innovation, and learning. This category also examines how the organization addresses its responsibilities to the public and how it supports the community.
- Based on the above indicators, describe one to three key strengths of the organization’s leadership.
- Based on the above indicators, describe one to three areas in which the organization’s leadership can improve.
Strategic Planning
This category examines how the organization develops strategic objectives and action plans and how progress toward the chosen strategic objectives is measured.
- Based on the above indicators, describe one to three key strengths of the organization’s strategic planning.
- Based on the above indicators, describe one to three areas of the organization’s strategic planning that can be improved.
Focus on Patients, Other customers, and Markets
This category examines how the organization determines requirements, expectations, and preferences of patients, other customers, and markets. It also examines how the organization builds relationships with patients and other customers and determines the key factors that lead to their acquisition, satisfaction, loyalty, and retention and to healthcare service expansion.
- Based on the above indicators, describe one to three key strengths in how the organization focuses on patients, other customers, and markets.
- Based on the above indicators, describe one to three opportunities that the organization can take to improve how it focuses on patients, customers, and markets.
Measurement, analysis, and Knowledge Management
This category examines how the organization selects, gathers, analyzes, manages, and improves its data, information, and knowledge assets.
- Based on the above indicators, describe one to three key strengths of the organization’s measurement, analysis, and knowledge management approaches.
- Based on the above indicators, describe one to three opportunities that the organization can take to improve its measurement, analysis, and knowledge management approaches.
Staff Focus
This category examines how the organization’s work systems and staff learning and motivation enable all staff to develop and utilize their full potential in alignment with the organization’s ove.
Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
Andreas Schleicher presents at the OECD webinar ‘Digital devices in schools: detrimental distraction or secret to success?’ on 27 May 2024. The presentation was based on findings from PISA 2022 results and the webinar helped launch the PISA in Focus ‘Managing screen time: How to protect and equip students against distraction’ https://www.oecd-ilibrary.org/education/managing-screen-time_7c225af4-en and the OECD Education Policy Perspective ‘Students, digital devices and success’ can be found here - https://oe.cd/il/5yV
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
We all have good and bad thoughts from time to time and situation to situation. We are bombarded daily with spiraling thoughts(both negative and positive) creating all-consuming feel , making us difficult to manage with associated suffering. Good thoughts are like our Mob Signal (Positive thought) amidst noise(negative thought) in the atmosphere. Negative thoughts like noise outweigh positive thoughts. These thoughts often create unwanted confusion, trouble, stress and frustration in our mind as well as chaos in our physical world. Negative thoughts are also known as “distorted thinking”.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Obesity is quickly becoming one of the most common chronic.docx
1. Obesity is quickly becoming one of the most common chronic
diseases among children. These rates have increased at an
alarming rate and is a major public health problem because of
related physical and psychological comorbidities, including type
II diabetes, insulin resistance, metabolic syndrome,
cardiovascular disease and mental health disorders. Dramatic
increase in the number of overweight and obese children in
recent years.
Studies indicate that children's lives may be shortened as a
result of this alarming health problem. Estimates state that for
any degree of overweight/obesity, younger adults (20-30 years
of age) may have greater years of life lost due to obesity than
older adults. Childhood obesity has been determined to be an
independent risk factor for adult overweight/obesity.
To combat childhood obesity, there is a great need for public
health interventions as well as education parents regarding
childhood obesity and its consequences. Parents differ on
causation of obesity, and differ in focus on nutrition and
physical exercise. Many parents in the research do not see
obesity as a barrier to physical activity. The parents need to
recognize their child as overweight. Prevention is the most
effective method for dealing with this growing health concern.
The evidence reviewed, confirmed that family-centered
interventions were associated with short-term reduction in
obesity and improved medical parameters. The goal should be to
involve community resources and provider referrals. Nurse
Practitioners have a unique role in being the best facilitators to
deliver health messages and are able to educate parents and
increase awareness about the causes and consequences of
2. childhood obesity.
Parents of young children need to interact with their child's
primary healthcare provider for health advice and preventive
health information during regularly scheduled physical
examinations. It is up to the parents of these young children to
combat intervention strategies such as:
a combination of nutritional and activity information, a
cognitive-behavioral aspect to the intervention parent-directed
activities
limiting sedentary child behaviors, provide positive approaches
with children by parents and practitioners (e.g., emphasize
positive rewards for healthy behaviors, encourage self-efficacy)
Future research is required to identify moderators and mediators
to produce enduring changes in weight status of children.
The Objective was to determine in children who are at risk for
becoming overweight or obese, does education with parental
involvement on exercise and nutrition compared to individual
education with the child alone decrease the risk of developing
obesity and the health problems associated with obesity?
(P) In overweight, obese, or at risk young children (2-18years
of age) Is family centered education/treatment interventions
(C) versus control or comparison interventions
(O) more effective in decreasing childhood obesity and
complications associated with it.
Background
Recommendations & Implications
A search was conducted in CHINAL, Pub Med, and Librarian at
Mount Marty College. Advanced key search works comprised
of the following; “childhood obesity”, “over weight”, “school-
aged,” and “Parental involvement.” The search was limited to
humans and English. Inclusion categories were Meta-Analysis,
Practice Guideline, and Randomized Control Trials. Articles
focusing on children aged 2-19 years of age.
Search StrategiesArticle 1Article 2Article 3Article 4Article
3. CitationNoori Akhtar-Danesh, Mahsid Dehghan, Katherine M
Morrison, Sujeewa Fonseka Jessica Doolen, MSN, FNP
(Lecturer), Patricia T. Alpert,
DrPH, APN, FAANP (Assistant Professor & Graduate
Coordinator), & Sally K. Miller,
PhD, APN, FAANP (Assistant Professor & Chair)
Patrica Tucker, MA, Jennifer D. Irwin, PhD, Faculty of Health
Sciences, University of Western Ontario, London,
ON;Evidence-Based Practice Center Systematic Review
Protocol
BackgroundIntervention: Both group received information
Intervention: Research related trialIntervention: Ten semi-
structured focus group interviews were conductedIntervention:
School-based interventionsPurposeTo investigate parents of
young children for their perceptions on the causes of obesity,
the impact of childhood obesity on health, and the barriers to
successful prevention of childhood obesityTo review the current
research literature on parental perceptions about their children's
weightTo determine the preschoolers' dietary intake behaviors
are described from the perspective of their parentsTo compare
the effectiveness of obesity intervention programs for children
and adolescents conducted in the United States and other
developed countriesMethodologyIntervention Period:6 months
Sample: 33 families (Conducted in two phases)
Outcome Measures: Parent & child changes in nutrition rate
Sample: Literature search using PubMed
Outcome Measures: Child BMI, self reported dietary and self
perception
Sample: 71 families
Outcome Measures: Body weight, BMI height and healthy food
choices
4. Follow Up: Immediately following the intervention and is
planned for years
Outcome Measures: Change in prevalence of obesity, change in
BMI or BMI distribution in the population and changes in
adiposity or other weight measuresKey FindingsDemonstration
of desired behavior change
Increased intake of fruits & vegetables
No overall significant group differences were found for any of
the measures
Parents were more likely to misperceive their child's weight
Parents' keen interest in their preschoolers' eating habits may
make them particularly receptive to learning about and
facilitating healthy choices in more behaviorally appropriate
waysSchool programs are effective in preventing childhood
obesity supports the need for broader implementation of
successful programsArticle 1Article 2Article 3
Article CitationN. Akhtar-Danesh, M. Dehghan, K M. Morrison,
S.Fonseka. (2010). Parents’ perceptions and attitudes on
childhood obesity: A Q-methodology study. Journal of the
American Academy of Nurse Practitioners. 23(2011) 67-
75.Wilfley, D. E., Van Buren, D. J., Reach, K. P., Walker, M.
S., & Epstein, L. H. (2007). Lifestyle Interventions in the
Treatment of Childhood Overweight: A meta-analytic review of
randomized controlled trials... Health Psychology, 26(5), 521-
532. doi: 10.1037/0278-6133.26.5.521.Kalarchian, M. A.,
Levine, M. D., Arslanian, S. A., Ewing, L. J., Houck, P. R.,
Ringham, R. M., ... Macus, M. R. (2009). Family-based
treatment of severe pediatric obesity: Randomized, controlled
trial... Pediatrics, 124; 1060. doi: 101.1542/peds.2008-
3727.Level of EvidenceLevel ILevel ILevel IPurpose of
Study
5. To investigate parents of young children for their perceptions
on the causes of obesity, the impact of childhood obesity on
health, and the barriers to successful prevention of childhood
obesity.
To use meta-analytic techniques to quantitatively evaluate the
efficacy of lifestyle interventions in the treatment of pediatric
overweight by comparing lifestyle interventions with wait-
list/no-treatment control groups or information/education only
control groups.To find interventions that were associated with
significant decrease of 7.58% in child overweight at 6 months
(that attended 75% if sessions) compared with a 0.66% decrease
with usual care.
Design/
Sample Size/
Q-Methodology was used to identify parents’ common attitudes
and perceptions. The research method used subjective
viewpoints that were analyzed using a combination of
qualitative and quantitative techniques.
Sample: 33 families (Conducted in two phases)
Interviews with a small sample of parents so as to complete a
questionnaire about views and attitudes towards childhood
obesity.
Outcome Measures: Parent & child changes in nutrition rate and
demonstration of desired behavior change
Strengths: this method is useful in research that explores
human perceptions and interpersonal relationships.
6. Limitation: Results of Q-studies are not usually generalizable
to the larger populations. The participants were homogenous in
their education. Education may have played a role in the
findings.14 Randomized control trials targeting change in
weight status were eligible, yielding 19 characteristics,
interventions, and results. Standardized coding was used to
extract information on design, participant characteristics,
interventions, and results.
Population: Youth age 19 and younger.
Sample size= RCT’s with usable information (n=14)
Variables=age, treatment length, number of sessions, sample
size, gender and type of weight outcome.
Outcome= lifestyle interventions for treatment of pediatric
overweight produce significant and clinically meaningful
changes in weight status in the short term compared with wait-
list/information only
Limitations: These analysis have limited role for moderators
and there was insufficient reporting of the design,
implementation, and analysis in the studies used for this
review..
A randomized, controlled trial at the University of Pittsburg
Medical Center . 192 children ages 8-12 years of age with
average BMI of 99.18. Families were randomly assigned to the
family based intervention group or the usual care. Assessments
were conducted at baseline, 6months, 12months, and 18months.
M Researchers examined factors associated with changes in
child percent overweight, and particularly session attendance.
Variables are 1) child age between 8-12 years, 2) child BMI of
greater-than or equal to 97th percentile, and 3) adult willingness
to participate in the program with the child. Outcomes:
significant short-term reductions in obesity and improvements
in medical parameters
Limitation: study did not control for time and attendance, study
7. had missing data on the medical outcomes.
Inclusion/ Exclusion
Criteria
Parents that attended a clinic for their well-baby check-up were
included in the study. No difference in age, BMI, or education.
Children older than 3 were excluded.
The studies selected for inclusion was a RCT of lifestyle
interventions focused on weight loss or weight control for youth
age 19 or younger that compared an active treatment with either
a wait-list/no-treatment control or with an
information/education only control. Study results in English
only, treatment duration of at least 4 weeks, and participants
overweight at baseline.
Reviewers coded all studies for intervention and outcome data
and resolved discrepancies through consultation and consensus
with study authors
Exclusion criteria included 1) mental retardation 2) psychiatric
symptoms requiring alternative treatment 3) genetic obesity
syndrome 4) current obesity treatment 5) inability to engage in
prescribed daily activity 6) medical conditions contraindicating
usual care, and 7) use of medication known to affect body
weight.
8. Chart1
Evidence Quality
Sheet1SalesLevel19Level 21Level 30level 40To resize chart
data range, drag lower right corner of range.
40 AJN t October 2007 t Vol. 107, No. 10
http://www.nursingcenter.com
How ToHow To
try thistry this
D
By Terry Fulmer, PhD, RN, FAAN
Continuing Education
2 HOURS
Ed
Ec
ks
te
9. in
Fulmer
A framework of six ‘marker conditions’ can help
focus assessment of hospitalized older patients.
SPICES
Overview: Fulmer SPICES is a framework for
assessing older adults that focuses on six common
“marker conditions”: sleep problems, problems
with eating and feeding, incontinence, confusion,
evidence of falls, and skin breakdown. These con-
ditions provide a snapshot of a patient’s overall
health and the quality of care. The SPICES assess-
ment, done regularly, can signal the need for more
specific assessment and lead to the prevention
and treatment of these common conditions. For a
free online video demonstrating the use of SPICES,
go to http://links.lww.com/A100.
L
ucy Semple, an 84-year-old resi-
dent of a long-term care facility,
was brought to the ED on a
Monday morning complaining of
hip pain. The previous morning
she had fallen on the way to the bathroom.
(This case is a composite, based on my expe-
rience.) At the time of the fall she insisted
that she was fine, but her pain worsened dur-
ing the day and she slept poorly that night.
10. Ms. Semple waited in the ED from 9 AM
until 2 PM on Monday. Because all of the
beds were full in the ED holding area, Ms.
Semple was left on a stretcher in the hallway.
At 2 PM she was taken for an X-ray, which
showed a fracture of the right femoral neck.
After the surgeon finished the evaluation, the
nurses prepared Ms. Semple for surgery. She had
not eaten since lunch on Sunday. She was taken to
the operating room at 5 PM on Monday. The oper-
ation lasted three hours, and she was brought to the
recovery room by 8:30 PM in moderate-to-severe
pain (8 out of 10 on a 0-to-10 Faces pain-rating
scale). Food and fluids were offered after she could
safely swallow, but she said her pain was making
her nauseated and she ate nothing.
Ms. Semple was transferred to the orthopedic
unit at 11 PM and received an opioid for pain
throughout the night. She slept poorly, at one point
screaming, “Operator, operator, where’s my
mother?” During morning rounds, a nurse sug-
gested that this “delightfully demented lady” would
“probably need haloperidol [Haldol] to control her
behavior.” It was further noted that there was a
small reddened area, without exudate, on her coc-
cyx and that she had been incontinent of urine dur-
ing the night and been placed in absorbent briefs.
THE NEED FOR THE SPICES FRAMEWORK
When I became a nurse in the 1970s, we had much
less evidence than we do now on how best to assess
common geriatric conditions. This often forced us
to rely on quick fixes that didn’t prevent or improve
those conditions. If someone was incontinent, for
11. example, a Foley catheter was inserted. Restraints
and medications were used to treat confusion. If
someone had trouble eating, a nasogastric tube was
inserted. To treat problems with sleep, sedatives
were given. When I became a geriatric nurse spe-
cialist, I’d go to a cardiac unit and say, “I’m Terry
Fulmer, and I’m here to help you care for your older
[email protected] AJN t October 2007 t Vol. 107, No. 10 41
patients. Do you have any problems that I might
help you with?” The nurses would usually say
something like, “No; the patient has an anterior
wall MI, and we’re working on getting the medica-
tion titrated and maybe there’ll be a pacemaker
inserted.”
It became clear that we needed a new frame-
work for assessing this population. The Nurses
Improving Care for Health System Elders
(NICHE) project has been identifying and helping
hospitals implement best practices for the care
of older adults since the early 1990s.1, 2 (See The
Atlantic Philanthropies Supports Better Care of
Older Adults, page 43.) The NICHE project helps
hospitals assess the quality of care they give to older
adults and provides four nursing-care models, evi-
dence-based protocols for assessing older adults,
and educational materials to help hospitals imple-
ment effective systemic changes.2, 3
The Fulmer SPICES framework, which was
developed in 1988,3 was implemented as part of the
geriatric resource nurse model of care in the
NICHE project. SPICES is an acronym that focuses
nurses on six “marker conditions” in older adults
12. rather than on the disease or injury for which a
patient was hospitalized. These conditions, also
sometimes referred to as syndromes, are common,
preventable, and may signal a need for more in-
depth assessment.
• Sleep disorders
• Problems with eating and feeding
• Incontinence
• Confusion
• Evidence of falls
• Skin breakdown
read it watch it try it
Web Video
Watch a video demonstrating the use and
interpretation of the Fulmer SPICES frame-
work at http://links.lww.com/A100.
A Closer Look
Get more information on the assessment
and care of older adults.
Try This: SPICES
This is SPICES in its original form.
See page 45.
42 AJN t October 2007 t Vol. 107, No. 10
http://www.nursingcenter.com
How ToHow To
try thistry this
D
13. The presence of these conditions, alone or in
combination, can lead to increased death rates,
higher costs, and longer hospitalizations in elderly
patients.4-7 The need for such a framework will
become even more urgent as the number of people
ages 65 to 84 doubles between 2000 and 2030,
from 30 million to more than 61 million, according
to U.S. Census Bureau projections.8 New models of
care will be needed in all settings to accommodate
the rapidly rising number of people living with one
or more chronic conditions.9
Hospitals face particular challenges; as Ms.
Semple’s case illustrates, there’s a great potential for
functional decline in hospitalized older adults. If a
SPICES assessment had been performed after Ms.
Semple’s first night of hospitalization, she would
have received a positive result for all six conditions.
MARKER CONDITIONS
It can be debated whether SPICES covers all the
conditions that are the most serious markers of
health in older patients. While constipation and
depression, for example, are also significant, the
SPICES framework is not a comprehensive list of
what can go wrong in a hospitalized older adult.
Rather, it’s intended to be a mnemonic device cov-
ering “geriatric vital signs” that, taken together,
provide a good overview of a geriatric patient’s
response to the care given and point to the need for
more detailed assessment when necessary.10 For
example, if the patient reports to a nurse perform-
ing a SPICES assessment that she or he is sleeping
poorly, further assessment might reveal that the
cause is inadequately controlled pain. In this way
14. the many complex connections among apparently
unrelated problems in older adults can become
clearer to nurses and help guide their plans of care.
Sleep disruption is common in hospitalized
patients.11, 12 While there have been no national
prevalence studies on sleep problems in hospital-
ized older adults, sleep disruption is common in
that population. (For more information, see “Sleep
Disruption in Older Adults,” May.) The stress of
hospitalization, being awakened for routine care,
pain, the effects of medications, changes in environ-
ment, and noise can all further compromise sleep
during hospitalization.
Assessing the patient. If a patient is cognitively
intact, you can simply ask, “How well do you usu-
ally sleep?” In the case of Ms. Semple, the nurses
could see that her sleep was fitful. Her pain and the
medication she received for it may have played a
role in her sleep disruption. Later, when she’s lucid,
she can be asked about her usual sleep patterns and
habits. Every effort must be made to create a good
environment for sleep for older adults; such mea-
sures might include minimizing conversation in
hallways and at the nurses’ station during sleeping
hours and limiting nursing interventions during this
time—which might, for example, mean postponing
a 4 AM blood pressure measurement if the patient is
clinically stable.
SPICES is one of the many assessment tools and
best practice approaches presented in the Hartford
Institute’s Try This: Best Practices in Nursing Care
to Older Adults (www.hartfordign.org/trythis).
15. Two Try This tools can be used to further evaluate
a patient whose SPICES assessment suggests there
is a sleep problem: The Epworth Sleepiness Scale
(www.hartfordign.org/publications/trythis/issue06.
pdf) and The Pittsburgh Sleep Quality Index (www.
hartfordign.org/publications/trythis/issue06_1.pdf).
More detail will be provided in upcoming articles
and videos in this series.
Problems with eating and feeding. One study
found that 20% of hospitalized older adults were
undernourished.13 Weight loss, low body mass index,
and malnutrition have repeatedly been associated
with higher mortality rates in older adults in all set-
tings.14, 15 These problems may be most apparent in
patients who are anorexic or unable to feed them-
selves. A small study of hospitalized older adults by
St-Arnaud-McKenzie and colleagues found close
associations between poorly controlled pain and
aversion to food and between hunger and a sense of
physical well-being.16 The ability to feed oneself is a
basic activity of daily living. Hospitalized older
adults often have practical difficulties when feeding
themselves: the bedside table is out of reach, utensils
are hard to use because of IV lines, or food is cold by
the time they are able to reposition themselves.
Assessing the patient. Ms. Semple’s nurses were
able to see that she had no appetite on the evening
immediately after her surgery; when asked why, she
reported that her pain was nauseating her. In order
to improve her appetite, better pain management is
required, and her desire and ability to eat should
be assessed again the following morning and
throughout her hospital stay. Research is needed to
improve our understanding of problems with eat-
16. ing and feeding in hospitalized older adults. For
a more detailed approach to assessment, see the
Try This tool Assessing Nutrition in Older Adults
(www.hartfordign.org/publications/trythis/issue_9.
pdf), which will be featured in a future article in
this series.
Incontinence, of either bladder or bowel, in hos-
pitalized older adults can vary in severity and may
result from delirium or dementia, reduced function
because of illness, medications that interfere with
the ability to detect bladder fullness, disrupted abil-
ity to walk to a bathroom or use a bedside com-
mode, and passive restraints such as IV lines,
catheters, or traction devices. Although urinary
incontinence, like weight loss, has shown close
associations with longer hospitalization, poor out-
come, and a poor sense of physical well-being,4, 17
one small exploratory study found that nurses often
view incontinence as inevitable in this population
and tend to use “containment” strategies such as
pads rather than promoting continence.18 A litera-
ture search turned up no recent prevalence and inci-
dence rates of incontinence in older hospitalized
patients, but in 1991 the Centers for Disease
Control and Prevention reported that from 1984 to
1987, 15% to 34% of hospitalized older adults had
urinary incontinence.19
Assessing the patient. Ms. Semple’s incontinence
was initially assessed through observation. When
she is oriented and responsive, she should be asked
such questions as “Do you usually have difficulty
17. reaching the toilet?” and “What can we do to help
you now?” Urinary incontinence can often be pre-
vented using interventions such as a voiding sched-
ule; once it does occur, it can be either acute and
reversible or chronic and irreversible. An indwelling
catheter should be used only as a last resort. Further
assessment of Ms. Semple’s incontinence might have
been done using the Try This tool Urinary Inconti-
nence Assessment (www.hartfordign.org/publications/
trythis/issue11.pdf), which will be featured in this
series.
Confusion, whether temporary or more long-
term, afflicts many hospitalized older adults. A
study at one hospital found that almost one-third of
patients age 70 or older suffered delirium within 24
hours of admission.20 And in a study of 118 consec-
utively admitted ICU patients ages 65 and older,
70% developed delirium in the ICU, as did 31% of
those with a “normal mental status” at the time of
admission.21 Hospitalization can disrupt older
adults’ eating and sleeping patterns and medication
dosages and schedules, which may disorient those
in an unfamiliar environment. Nurses should assess
older patients for confusion, attempt to prevent its
occurrence, and intervene to reverse and alleviate
the fear that this condition can provoke.
Assessing the patient. Ms. Semple’s confusion was
[email protected] AJN t October 2007 t Vol. 107, No. 10 43
The Atlantic Philanthropies has awarded the HartfordInstitute
for Geriatric Nursing, part of New York
University’s College of Nursing, a $5 million, five-year grant
18. to expand its NICHE (Nurses Improving Care for Health
System Elders) program. Since 1996, the Hartford Institute
has administered NICHE, which has as its vision that all
patients ages 65 and older be given sensitive and exem-
plary care. NICHE is a national geriatric nursing program
that helps hospitals achieve systematic nursing change to
benefit older patients. It is currently implemented in 225 hos-
pitals in more than 40 states and parts of Canada.
Many nurses are unaware of the ways in which older
adults differ from younger patients in terms of symptoms
and appropriate treatment. Hospitals are recognizing that
such teaching is necessary to prepare their organizations
for the future. The Atlantic Philanthropies grant will help
NICHE build its internal capacity, dramatically improve the
program’s “tool kit”—particularly its measurement and
reporting capacity—and initiate outreach to accelerate
adoption of the program by additional hospitals.
When hospitals first join the NICHE program, they send a
team to a conference where they learn about the various ele-
ments of the NICHE tool kit. NICHE is a modular program
that offers hospitals an array of options to improve their nurs-
ing resources for older adults. The most frequently used com-
ponent, the Geriatric Resource Nurse model, helps hospitals
train interested and motivated nurses in best practices for the
care of older adults. These nurses then become resources for
their colleagues, and many go on to become certified in
gerontologic nursing. Some hospitals have adopted the
Acute Care of the Elderly model, and others have instituted
hospital-wide programs to address specific issues such as
falls prevention, skin care, incontinence, and delirium.
The NICHE program aims to expand to 600 or more
hospitals during the five-year grant period. The project’s
19. current plan includes regional and audio conferences and
a new Web site for NICHE members that will offer interac-
tive, Wikipedia-type technology, enabling users to share
information about best practices in the care of older adults.
For more information, go to www.nicheprogram.org.—Liz
Capezuti, PhD, RN, APRN-BC, FAAN, associate professor
and codirector, John A. Hartford Foundation Institute for
Geriatric Nursing, New York University College of
Nursing, New York City: [email protected]
The Atlantic Philanthropies Supports
Better Care of Older Adults
The NICHE program now has a strong mandate to expand its
programs.
44 AJN t October 2007 t Vol. 107, No. 10
http://www.nursingcenter.com
How ToHow To
try thistry this
D
first assessed through observation. The nurse’s com-
ment that Ms. Semple was “delightfully demented”
suggests the assumption, common among health care
providers, that all older adults in long-term care have
dementia; it also reveals a lack of communication
with the long-term care facility staff about the
patient’s usual mental status as well as with the ED
staff about her mental status at the time of admis-
sion. The suggestion to give haloperidol may have
been premature because Ms. Semple’s change in
cognitive status might have been alleviated by
20. reducing her pain medication or by engaging a fam-
ily member to help orient her. Ms. Semple’s nurses
could have used the following Try This tools for
more detailed assessment of Ms. Semple’s mental
status: Mental Status Assessment of Older Adults:
The Mini-Cog (www.hartfordign.org/publications/
trythis/issue03.pdf) and The Confusion Assessment
Method (www.hartfordign.org/publications/trythis/
issue13.pdf), both of which will be featured in this
series.
Evidence of falls. According to a literature
review by Tinetti and colleagues, approximately
30% of community-dwelling adults ages 65 and
older fall each year.22 Stevens and colleagues esti-
mated the cost of nonfatal falls among people in the
United States ages 65 and older in 2000 to have
been more than $19 billion.23 A literature review by
Oliver and colleagues notes that the most consis-
tently identified risk factors for falls in hospitalized
patients are confusion, gait instability, urinary
incontinence or frequency, a history of falls, and the
administration of sedatives and hypnotic drugs.24 A
program instituted by Fonda and colleagues
reduced falls by 19% over a two-year period at a
hospital for the elderly in Australia; the program
reviewed toileting protocols and instituted the use
of nonslip bedside mats, identification and surveil-
lance of patients at risk for falling, glow-in-the-dark
commode seats, and staff orientation on falls pre-
vention, among other measures.25 It’s important to
determine which hospitalized older adults have a
history of falls and take measures to anticipate and
prevent them. If a patient who has no history of falls
does so while in the hospital, assessment and treat-
21. ment should focus on identifying possible iatrogenic
causes.
Assessing the patient. Ms. Semple’s hospitaliza-
tion was known to be the result of a fall. When she
is able to answer, she can be asked, “Is this the first
time you’ve fallen?” The long-term care facility
should also be consulted to find out whether Ms.
Semple has a history of falls. The fact that she fell in
the long-term care facility and her SPICES assess-
ment was positive for evidence of falls should moti-
vate her nurses to further assess her risk of future
falls by using a tool such as Fall Risk Assessment
for Older Adults: The Hendrich II Model (www.
hartfordign.org/publications/trythis/issue08.pdf), to
be highlighted in a future article in this series.
Skin breakdown—specifically pressure ulcers—
can be fatal in older adults. The one-day 1999
National Pressure Ulcer Prevalence Survey found
that of nearly 43,000 acute care patients, 14.8%
had a pressure ulcer; 61% of these were in patients
age 71 or older.26 Skin breaks down in immobilized
patients when pressure reduces the blood supply to
an area and the tissue dies. Some of the major risk
factors and causes are older age; bed rest; neuropa-
thy, which can impair the detection of pain; poor
nutrition; cognitive impairment, which can impede
self-care or recognition of a problem; friction and
shearing against bedsheets; and urinary inconti-
nence resulting in moisture in areas over bony
prominences.
Assessing the patient. Ms. Semple had several of
the above risk factors. The redness on her coccyx
was identified through physical examination and
22. should have immediately led to measures to prevent
the progression of skin breakdown, such as the use
of a pressure-relieving mattress, turning every two
hours, putting her on a voiding schedule instead of
applying absorbent pads, and using a pressure ulcer
assessment tool such as the Braden Scale for Predicting
Pressure Sore Risk (see Try This, Predicting Pressure
Ulcer Risk, www.hartfordign.org/publications/trythis/
issue05.pdf).
Go to http://links.lww.com/A100 towatch a nurse use the
Fulmer SPICES to
assess an older woman for common geriatric
problems and discuss ways to meet the chal-
lenges of administering it and interpreting
and quickly acting on findings. Then watch
the health care team plan short- and long-
term interventions to address the woman’s
condition.
View this video in its entirety and then
apply for CE credit at www.nursingcenter.
com/AJNolderadults; click on the How to
Try This series. All videos are free and in a
downloadable format (not streaming video)
that requires Windows Media Player.
Watch It!
Issue Number 1, Revised 2007 Series Editor: Marie Boltz, PhD,
APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing
23. Fulmer SPICES: An Overall Assessment Tool for Older Adults
By: Meredith Wallace, PhD, APRN, CS, Fairfield University
School of Nursing, and
Terry Fulmer, PhD, APRN, GNP, FAAN, New York University
College of Nursing
WHY: Normal aging brings about inevitable and irreversible
changes. These normal aging changes are partially
responsible for the increased risk of developing health-related
problems within the elderly population. Prevalent
problems experienced by older adults include: sleep disorders,
problems with eating or feeding, incontinence, confusion,
evidence of falls, and skin breakdown. Familiarity with these
commonly-occurring disorders helps the nurse prevent
unnecessary iatrogenesis and promote optimal function of the
aging patient. Flagging conditions for further assessment
allows the nurse to implement preventative and therapeutic
interventions (Fulmer, 1991; Fulmer, 1991).
BEST TOOL: Fulmer SPICES, developed by Terry Fulmer,
PhD, APRN, FAAN at New York University College of
Nursing,
is an efficient and effective instrument for obtaining the
information necessary to prevent health alterations in the older
adult patient (Fulmer, 1991; Fulmer, 1991; Fulmer, 2001).
SPICES is an acronym for the common syndromes of the
elderly requiring nursing intervention:
S is for Sleep Disorders
P is for Problems with Eating or Feeding
I is for Incontinence
C is for Confusion
E is for Evidence of Falls
S is for Skin Breakdown
24. TARGET POPULATION: The problems assessed through
SPICES occur commonly among the entire older adult
population. Therefore, the instrument may be used for both
healthy and frail older adults.
VALIDITY AND RELIABILITY: The instrument has been used
extensively to assess older adults in the hospital setting,
to prevent and detect the most common complications (Fulmer,
2001; Lopez, et al, 2002; Pfaff, 2002; Turner, J., et al,
2001; NICHE). Psychometric testing has not been done.
STRENGTHS AND LIMITATIONS: The SPICES acronym is
easily remembered and may be used to recall the common
problems of the elderly population in all clinical settings. It
provides a simple system for flagging areas in need of further
assessment and provides a basis for standardizing quality of
care around certain parameters. SPICES is an alert system
and refers to only the most frequently-occurring health
problems of older adults. Through this initial screen, more
complete assessments are triggered. It should not be used as a
replacement for a complete nursing assessment.
Permission is hereby granted to reproduce, post, download,
and/or distribute, this material in its entirety only for not-for-
profit educational purposes only, provided that
The Hartford Institute for Geriatric Nursing, College of
Nursing, New York University is cited as the source. This
material may be downloaded and/or distributed in electronic
format, including PDA format. Available on the internet at
www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail
notification of usage to: [email protected]
[email protected] AJN t October 2007 t Vol. 107, No. 10 45!
26. Model. Journal of
Nursing Administration, 32(11), 577-585.
Nurses Improving the Care of the Hospitalized Elderly (NICHE)
project at the Hartford Institute for Geriatric Nursing,
http://www.hartfordign.org.
Pfaff, J. (2002). The Geriatric Resource Nurse Model: A culture
change. Geriatric Nursing, 23(3), 140-144.
Turner, J. T., Lee, V., Fletcher, K., Hudson, K., & Barton, D.
(2001). Measuring quality of care with an inpatient elderly
population: The geriatric
resource nurse model. Journal of Gerontological Nursing, 27(3),
8-18.
A SERIES PROVIDED BY
The Hartford Institute for Geriatric Nursing
EMAIL: [email protected]
HARTFORD INSTITUTE WEBSITE: www.hartfordign.org
CONSULTGERIRN WEBSITE: www.ConsultGeriRN.org
#46 AJN t October 2007 t Vol. 107, No. 10
http://www.nursingcenter.com
[email protected] AJN t October 2007 t Vol. 107, No. 10 47
established. Face validity has been established with
one interdisciplinary group at one hospital3, 10 and
should be replicated, and formal content-validity
testing has been conducted at diverse work sites.
The effect of the racial and ethnic backgrounds of
nurses and patients on the administration of SPICES
has not been tested and is open to research. t
27. Terry Fulmer is the Erline Perkins McGriff professor and
dean of the College of Nursing at New York University
(NYU), New York City. She is also a codirector of the John
A. Hartford Foundation Institute for Geriatric Nursing.
Contact author: [email protected]
How to Try This is a three-year project funded by a grant
from the John A. Hartford Foundation to the Hartford
Institute for Geriatric Nursing at NYU’s College of Nursing in
collaboration with AJN. This initiative promotes the Hartford
Institute’s geriatric assessment tools, Try This: Best Practices
in
Nursing Care to Older Adults: www.hartfordign.org/trythis. The
print series will include 30 articles and corresponding videos,
all
of which will be available for free online at www.nursingcenter.
com/AJNolderadults. Sherry A. Greenberg, MSN, APRN, BC,
GNP ([email protected]), and Nancy A. Stotts,
EdD, RN, FAAN ([email protected]), are coedi-
tors of the series. These articles and videos are to be used for
educational purposes only.
Routine use of a Try This tool may require formal review
and approval by your employer.
REFERENCES
1. Geriatric models of care: which one’s right for your institu-
tion? Nurses Improving Care to the Hospitalized Elderly
(NICHE) Project. Am J Nurs 1994;94(7):21-3.
2. Mezey M, et al. Nurses Improving Care to Health System
Elders (NICHE): implementation of best practice models. J
Nurs Adm 2004;34(10):451-7.
3. Fulmer TT. The geriatric nurse specialist role: a new model.
28. Nurs Manage 1991;22(3):91-3.
4. Anpalahan M, Gibson SJ. Geriatric syndromes as predictors
of adverse outcomes of hospitalization. Intern Med J 2007.
Epub ahead of print.
For more information on SPICES and other geriatric assess-
ment tools and best practices, go to www.hartfordign.org,
the Web site of the John A. Hartford Foundation–funded
Hartford Institute for Geriatric Nursing at New York
University College of Nursing. The institute focuses on
improving the quality of care provided to older adults by
promoting excellence in geriatric nursing practice, educa-
tion, research, and policy. Download the original Try This
document on SPICES by going to www.hartfordign.org/
publications/trythis/issue01.pdf.
To see links to many geriatrics institutions and asso-
ciations, as well as gerontology-related journals and
resources, curriculum guides, gerontology and education
centers, and listservs, go to www.hartfordign.org/links/
geriatric_links.html.
And go to www.nursingcenter.com/AJNolderadults and
click on the How to Try This link to access all articles and
videos in this series.
Online Resources
USING SPICES
In most cases the SPICES framework will be used
to complement other, more detailed assessment
strategies. A SPICES card can be completed on the
day of admission and on each day of hospitaliza-
tion for each patient age 65 or older. The card can
be created and reproduced by using a three-by-five-
inch index card with S–P–I–C–E–S written on the
29. vertical axis and yes and no check boxes by each
condition. (See Fulmer SPICES: An Overall
Assessment Tool for Older Adults, page 45). In set-
tings using electronic medical records, the card can
be converted to an electronic file.
Positive responses should be noted in the
patient’s record, and preventive strategies should be
detailed for any of the six marker conditions not
present on assessment. Positive responses should
lead to more detailed assessment. For example, if a
patient is positive for “skin breakdown” or for the
erythema that precedes skin breakdown, the nurse
can then apply a well-established assessment tool
such as the Braden Scale.
The bigger picture. The SPICES framework can
also be used for unit-wide quality improvement. As
nurses begin to see patterns emerging in their unit’s
SPICES data, they can review the literature for best-
practice protocols. In a study conducted on one
pulmonary and renal unit, each nurse filled out a
SPICES card for every patient over the age of 65 for
one month, with the goal of creating a nutritional
screening tool.27 They compiled data from more
than 200 cards and found that sleep problems and
problems with eating and feeding were the most
prevalent conditions documented. Although these
results were not surprising (many of the patients
had difficulty breathing or were metabolically
unstable because of renal disease), the data helped
the nurses determine which patients needed more
detailed assessment. This information also helped
them establish clinical practice protocols for older
adults on the unit, such as assessing for medications
that might decrease appetite or offering patients
30. their main meal at either lunch or breakfast.
The SPICES card can likewise help nurses see
what did not happen on the unit in any given
period. If a cardiac unit collects SPICES cards for
older adults for an entire month and can report that
there have been no documented SPICES conditions,
that success will only reinforce the effectiveness of
determining and implementing best practices.
CONSIDER THIS
Psychometric testing of the SPICES framework has
been minimal, and interrater reliability has not been
48 AJN t October 2007 t Vol. 107, No. 10
http://www.nursingcenter.com
How ToHow To
try thistry this
D
5. Ensrud KE, et al. Frailty and risk of falls, fracture, and mor-
tality in older women: the study of osteoporotic fractures. J
Gerontol A Biol Sci Med Sci 2007;62(7):744-51.
6. Landi F, et al. Pressure ulcer and mortality in frail elderly
people living in community. Arch Gerontol Geriatr 2007;44
Suppl 1:217-23.
7. Wakefield BJ, Holman JE. Functional trajectories associated
with hospitalization in older adults. West J Nurs Res
2007;29(2):161-77.
31. 8. U.S. Census Bureau. Table 2a. Projected population of the
United States, by age and sex: 2000 to 2050. Washington,
DC; 2004. http://www.census.gov/ipc/www/usinterimproj/
natprojtab02a.pdf.
9. American Hospital Association. When I’m 64: how
boomers will change health care. Chicago; 2007 Jul.
http://www.aha.org/aha/content/2007/pdf/070508-boomer-
report.pdf.
10. Inouye SK, et al. The Yale Geriatric Care Program: a model
of care to prevent functional decline in hospitalized elderly
patients. J Am Geriatr Soc 1993;41(12):1345-52.
11. Freedman NS, et al. Patient perception of sleep quality and
etiology of sleep disruption in the intensive care unit. Am J
Respir Crit Care Med 1999;159(4 Pt 1):1155-62.
12. Tranmer JE, et al. The sleep experience of medical and sur-
gical patients. Clin Nurs Res 2003;12(2):159-73.
13. Guigoz Y, et al. Identifying the elderly at risk for malnutri-
tion. The Mini Nutritional Assessment. Clin Geriatr Med
2002;18(4):737-57.
14. Kagansky N, et al. Poor nutritional habits are predictors of
poor outcome in very old hospitalized patients. Am J Clin
Nutr 2005;82(4):784-91.
15. Nguyen ND, et al. Bone loss, weight loss, and weight fluc-
tuation predict mortality risk in elderly men and women. J
Bone Miner Res 2007;22(8):1147-54.
16. St-Arnaud-McKenzie D, et al. Hunger and aversion: drives
that influence food intake of hospitalized geriatric patients.
J Gerontol A Biol Sci Med Sci 2004;59(12):1304-9.
32. 17. Teunissen D, et al. “It can always happen”: the impact of
urinary incontinence on elderly men and women. Scand J
Prim Health Care 2006;24(3):166-73.
18. Dingwall L, McLafferty E. Do nurses promote urinary con-
tinence in hospitalized older people? An exploratory study. J
Clin Nurs 2006;15(10):1276-86.
19. Urinary incontinence among hospitalized persons aged 65
years and older—United States, 1984–1987. MMWR Morb
Mortal Wkly Rep 1991;40(26):433-6.
20. Edlund A, et al. Delirium in older patients admitted to gen-
eral internal medicine. J Geriatr Psychiatry Neurol
2006;19(2):83-90.
21. McNicoll L, et al. Delirium in the intensive care unit: occur-
rence and clinical course in older patients. J Am Geriatr Soc
2003;51(5):591-8.
22. Tinetti ME, et al. Fall-risk evaluation and management:
challenges in adopting geriatric care practices. Gerontologist
2006;46(6):717-25.
23. Stevens JA, et al. The costs of fatal and non-fatal falls
among older adults. Inj Prev 2006;12(5):290-5.
24. Oliver D, et al. Risk factors and risk assessment tools for
falls in hospital in-patients: a systematic review. Age Ageing
2004;33(2):122-30.
25. Fonda D, et al. Sustained reduction in serious fall-related
injuries in older people in hospital. Med J Aust
2006;184(8):379-82.
33. 26. Amlung SR, et al. The 1999 National Pressure Ulcer
Prevalence Survey: a benchmarking approach. Adv Skin
Wound Care 2001;14(6):297-301.
27. Phaneuf C. Screening elders for nutritional deficits. Am J
Nurs 1996;96(3):58-60.
GENERAL PURPOSES: To present registered professional
nurses with information on Fulmer SPICES, a framework
for assessing older adults that focuses on six common
“marker conditions” and provides a snapshot of overall
health and quality of care.
LEARNING OBJECTIVES: After reading this article and taking
the test on the next page, you will be able to
• present an overview of the SPICES framework for assess-
ing older adults.
• review the background information on the need for and
basis of the SPICES framework.
• plan the appropriate interventions for marker conditions
that the framework identifies.
TEST INSTRUCTIONS
To take the test online, go to our secure Web site at www.
nursingcenter.com/CE/ajn.
To use the form provided in this issue,
• record your answers in the test answer section of the CE
enrollment form between pages 56 and 57. Each ques-
tion has only one correct answer. You may make copies
of the form.
• complete the registration information and course evalua-
34. tion. Mail the completed enrollment form and registration
fee of $19.95 to Lippincott Williams and Wilkins CE
Group, 2710 Yorktowne Blvd., Brick, NJ 08723, by
October 31, 2009. You will receive your certificate in four
to six weeks. For faster service, include a fax number and
we will fax your certificate within two business days of
receiving your enrollment form. You will receive your CE
certificate of earned contact hours and an answer key to
review your results. There is no minimum passing grade.
DISCOUNTS and CUSTOMER SERVICE
• Send two or more tests in any nursing journal published by
Lippincott Williams and Wilkins (LWW) together, and
deduct $0.95 from the price of each test.
• We also offer CE accounts for hospitals and other health
care facilities online at www.nursingcenter.com. Call
(800) 787-8985 for details.
PROVIDER ACCREDITATION
LWW, publisher of AJN, will award 2 contact hours for
this continuing nursing education activity.
LWW is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
LWW is also an approved provider of continuing nurs-
ing education by the American Association of Critical-
Care Nurses #00012278 (CERP category A), District of
Columbia, Florida #FBN2454, and Iowa #75. LWW
home study activities are classified for Texas nursing con-
tinuing education requirements as Type 1. This activity
is also provider approved by the California Board of
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40 AJN ▼ October 2004 ▼ Vol. 104, No. 10
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OVERVIEW: Although people age at different rates, changes to
the com-
position of the human body are a hallmark of aging. As a result
of such
changes, disease can present differently in a person over 65
years old than
it would in a younger adult or child. This article identifies the
critical
indicators of underlying conditions, including changes in mental
36. status,
loss of function, decrease in appetite, dehydration, falls, pain,
dizziness,
and incontinence. It also describes the presentation of diseases
common
to older adults, including depression, infection, cardiac disease,
gastroin-
testinal disorders, thyroid disease, and type 2 diabetes.
PRESENTATION
of ILLNESS in
OLDER ADULTS
If you think you know what you’re
looking for, think again.
Elaine J. Amella is an associate dean for research and an
associate professor at Medical University of
South Carolina College of Nursing, Charleston. Contact author:
[email protected] This article is the
second in a series that’s supported in part by a grant from the
Atlantic Philanthropies to the
Gerontological Society of America. Nancy A. Stotts, EdD, RN,
FAAN ([email protected]),
and Carole E. Deitrich, MS, GNP, RN ([email protected]), are
the series editors. The
author of this article has no significant ties, financial or
otherwise, to any company that might have an
interest in the publication of this educational activity.
By Elaine J. Amella, PhD, APRN,BC
O SINGLE, CHRONOLOGICAL TIMETABLE OF HUMAN
AGING EXISTS.”
This is one conclusion of the Baltimore Longitudinal Study on
Aging,
37. which since 1958 has tracked more than 1,000 people from age
20 to over
age 90 in an attempt to define “normal” physiologic human
aging.1
Although in most aging people cardiac muscles thicken, arteries
stiffen,
lung tissues diminish, brain and spinal cord degenerate, kidneys
shrink, and
bladder muscles weaken, they do so at varying rates in different
people. In
fact, organs age at different rates within each person; for
example, lungs
can continue going strong as kidneys begin to fail.
[email protected] AJN ▼ October 2004 ▼ Vol. 104, No. 10 41
Taken from Aging in America: The Years Ahead, by
photographer Ed Kashi and writer Julie Winokur.
Adding to the confusion is the fact that people
over 65 years old (“older adults”) take more med-
ications than their younger counterparts; this
polypharmacy can lead to a change of mental sta-
tus, a symptom that may mistakenly be attributed
to old age. In short, to inadequately trained clini-
cians, some normal aspects of aging can appear as
manifestations of disease while other changes can
mask early signs of illness.2 For example, a
decreased ability to regulate body temperature puts
older adults at higher risk for hypothermia, and it
38. also decreases their ability to promptly respond to
pathogens by initiating an inflammatory process
(through fever). This can lead to the overtreatment
of a relatively healthy person or cause a clinician to
miss important clues of an acute disorder requiring
treatment.
To differentiate disease from normal aging
requires assessment skills developed specifically for
the older adult and an understanding of the aging
process, as well as an understanding of the factors
that produce altered presentations of several ill-
nesses in older adults.
HOW THE BODY AGES
While it’s been acknowledged that family history,
environment, and lifestyle influence aging, there are
many theories as to which physiologic changes
cause the body to age—and how they do so. While
research continues, one fact is incontrovertible:
changes in overall body composition are a hallmark
of aging.
Alterations in cell replication. One significant
change is how cells replicate. Much of what we rec-
ognize as aging is governed by changes in cells’ abil-
ity to reproduce over a lifetime. Researchers have
identified telomeres, the stretches of DNA that pro-
tect both ends of chromosomes, as an important
factor in human aging. Human cells are thought to
divide about 50 to 70 times over a lifetime.3 With
each replication, telomeres shorten, allowing chro-
mosomes to stay intact. Over time, telomeres
shorten until the cell is no longer able to replicate,
resulting in cell death, or senescence. While “limited
replication or ‘replicative senescence’ is no longer
39. seen as the main issue of ageing—nonetheless, los-
ing the ability to divide may well undermine tissues
that must produce fresh cells quickly. For instance,
it could hamper the immune system’s capacity to
respond to novel pathogens and may underlie the
slower wound healing of the elderly.”4
Oxidative stress is the damage caused to cellular
proteins by free radicals, the toxic compounds
released by the metabolism of oxygen and also
found in the environment (for example, in smoke
and smog). Cigarette smoking, poor diet, and other
lifestyle factors can also trigger free-radical activity.
Over the course of a lifetime, free radicals bombard
42 AJN ▼ October 2004 ▼ Vol. 104, No. 10
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CASE STUDY
What’s causing this patient’s confusion?
Three days after undergoing an open reduction and inter-nal
fixation of a fractured hip, 82-year-old Carol
Thompson is admitted to the hospital after her daughter found
her bruised body crumpled at the bottom of a flight of stairs.
Although once very independent, Ms. Thompson is now con-
fused and uncooperative. She is pulling at her dressing and
unwilling to keep her hip-abduction pillow in place. The
social worker recommends placement in a nursing home.
You suspect that something else could be causing Ms.
Thompson’s decline. From the chart you learn she fell
down poorly lighted stairs and lay there for more than 18
hours before being found. Suspecting a slow bleed into
her brain from a subdural hematoma, you wonder if any-
one has determined if Ms. Thompson hit her head when
40. she fell. You check her pupils and her major cranial
nerves. Because she was dehydrated on admission, she
received a large amount of IV fluids. Wondering if she
received too much too quickly—perhaps worsening unde-
tected heart disease—you check her pulses and blood
pressure and note any edema or neck-vein distention. You
ask her daughter to bring in her medicine vials, and note
that her daily levothyroxine (Synthyroid) was not ordered
since admission.
Ms. Thompson’s surgery was complicated and lasted
longer than expected; she did not receive a transfusion.
You wonder if she might still be recovering from the anes-
thesia and check to see if hemoglobin and hematocrit lev-
els were checked postoperatively; they were tested only on
day one. Despite pressurized devices and the use of anti-
coagulant, you consider that she might have had a small
stroke or other vascular insult. Finally, you wonder about
pain management. Not only is Ms. Thompson recovering
from major surgery, but she also has significant arthritis.
Could her pain be adequately treated with the opioid anal-
gesic ordered? You check her vital signs, perform a neuro-
logic examination, assess for delirium using the Confusion
Assessment Method, note her comfort level using the
Checklist of Nonverbal Pain Indicators, examine her oral
mucosa and conjunctiva for paleness, and review her med-
ication record using the Beers Criteria for Potentially
Inappropriate Medication Use in the Elderly.
In consultation with the orthopedic surgeon and the
nurse practitioner managing her care, you arrange for the
levothyroxine to be restarted, blood work to be drawn,
and a change in pain medication to a sustained-release
and breakthrough morphine agent. You also ask her
daughter to meet with health care providers to discuss a
longer hospital stay—until the medical issues causing this
41. possible delirium can be addressed. You arrange for her
daughter to visit outside of visiting hours and you remind
her to bring in her mother’s eyeglasses.
Ms. Thompson’s delirium begins to lift in about 24
hours. Within 48 hours, she is participating with her treat-
ment plan and looking forward to returning home.
cells, eventually causing cell mutation and senes-
cence; as a result, oxidative stress has been recog-
nized as a factor in the pathogenesis of cancer and
heart disease. A link to the general decline in physi-
ologic functioning that occurs with age has also
been hypothesized.5
INDICATORS
Early recognition of indicators of underlying health
problems, including change in mental status, falls,
dehydration, decrease in appetite, pain, loss of func-
tion, dizziness, and incontinence, can mean an oppor-
tunity to initiate treatment while recovery is still
possible.6 (These problems aren’t inherent to aging.)
An in-depth examination is required to determine
cause, especially because some indicators have both
physiologic and psychological origins. (See Aging of
the Body’s Systems, page TK.) Key to providing
appropriate treatment to older adults is establishing
a baseline that goes beyond the usual history and
physical parameters to examine mental, functional,
nutritional, and social-support status. A history that
contains information about the health of siblings,
partners, and children can provide clues to family
42. history, environment, and lifestyle. Baseline informa-
tion should be gathered upon admission to a facility,
and whenever the patient’s condition changes.
Community-dwelling older adults should be
assessed at least once a year. More frequent evalua-
tions are warranted for patients with chronic prob-
lems, such as memory loss or joint disease.
Change in mental status is a common harbinger
of disease, drug toxicity, or psychological trauma in
older adults. The primary causes of delirium and
acute states of confusion are adverse effects from
medication, drug–drug interactions, or toxic levels
of medication in the blood.7 Whenever older
patients are unable to focus their thoughts or expe-
rience a sudden change in mental status (occurring
over one day, a few days, or even weeks), the nurse
should suspect medication toxicity. This is especially
important when the patient has recently received
anesthesia or new medications. The assumption
that older adults are normally confused is incorrect
[email protected] AJN ▼ October 2004 ▼ Vol. 104, No. 10 43
MED SURGE
With age, the body’s reaction to medication changes.
For Groucho Marx, old age was not a subject of rever-ence.
“Anyone can get old,” he said. “All you have to
do is live long enough.” Of course, a clinician knows what
a comedian doesn’t: living “long enough” these days usu-
ally entails a medication regimen—and with this comes a
high risk of adverse drug events and drug–drug interac-
tions. The fact is, even in otherwise healthy older adults,
changes in body composition influence the absorption, dis-
tribution, and clearance of medications.30
43. Absorption. According to Williams, “In older persons,
absorption is generally complete, just slower. In addition to
age-related changes, common medical conditions such as
heart failure may reduce the rate and extent of absorption.”30
Distribution. As people age, they lose lean body mass
gain and adipose tissue gain. Because there is less fluid
available, water-soluble medications can reach toxic levels
more quickly. Furthermore, the increase in adipose tissue
means that fat-soluble drugs (predominantly the psychotrop-
ics) are absorbed into these less well-vascularized fat stores,
and it takes longer for the drug to reach a therapeutic level
(as well as longer for them to be excreted from the system).
Vigilant monitoring is required with potentially nephrotoxic
medications, including antimicrobials, cardiovascular
agents, H2-antagonists, oral hypoglycemics (especially the
sulfonylureas), and nonsteroidal antiinflammatory agents.
Protein malnutrition is common in underweight and obese
older adults. This means that there are fewer binding sites for
protein-binding drugs such as warfarin (Coumadin and others)
or phenytoin (Dilantin and others); causing more “free” drug
to circulate and putting the patient at greater risk for adverse
effects such as bleeding or confusion. Protein malnutrition is
determined by using prealbumin level less than 15 mg/dL,
serum albumin level less than 3.2 g/dL, total lymphocyte count
less than 1500 � mm3, transferrin level less than 200 mg/dL,
and serum cholesterol level less than160 mg/dL.31
Clearance. With decrease in kidney and liver function-
ing, clearance and excretion of drugs also takes longer. The
nurse needs to closely monitor serum protein level (normal
range 5.5 to 9.0 g/dL) and albumin level (normal range
3.5 to 5.5 g/dL), as well as renal and liver functions to help
44. the older patient avoid toxicity or undertreatment.32
Assessing kidney function and drug toxicity. Measures of
serum creatinine, used to assess excretion for many drugs,
are related to muscle mass and thus aren’t a good measure
of kidney functioning in a frail individual or one who has lost
muscle mass due to immobility. Contact the physician or
pharmacist if there’s any doubt regarding the nephrotoxicity
of the drug, and use the Cockcroft–Gault formula to calculate
the creatinine clearance (see Cockcroft–Gault Equation for
Calculating Creatinine Clearance, page TK). Creatinine
clearance, a measure of the glomerular filtration rate, is a
valuable way to note decline in kidney function in older
adults. Accepted clearances are published for each drug,
but the nurse should be especially concerned in patients with
a clearance of less than 50 mL/min, which is indicative of a
prerenal state.33 The pharmacist should be consulted about
the need for dose adjustment, and monitoring of renal func-
tion should continue.
Presence of these signs point to a diagnosis of delir-
ium and warrant a complete diagnostic assessment.
Falls don’t necessarily imply a change in condi-
tion; however, the circumstances of a fall should be
investigated to determine whether the cause was
environmental or health related. In short, a new
onset of falls should always be seen as a symptom
of illness until proven otherwise. Falls should be
considered within the context of the following com-
plex problems:
• cardiac—syncope, orthostasis, cardiac arrhythmias
• musculoskeletal—poor posture, osteoporosis,
45. loss of strength
• neurologic—poor balance and gait, vertigo, and
dizziness
• change in mental status—a slow intracranial
hemorrhage
• sensory—loss of vision or hearing, poorly lighted
areas
• functional—general weakness
• continence—slipped on urine, hurrying to bath-
room
• psychological—fear of falling, unusual limitation
of activities
In determining the details of the fall, ask: Did the
person black out or feel dizzy prior to the fall?
Could he have hit his head when he fell? Was he
wearing eyeglasses or a hearing aid, if needed?
While numerous assessments should be done, sev-
eral are critical: complete a baseline mental status
examination; question the patient about dizziness
(see “Dizziness,” below); assess orthostasis through
lying, seated, and standing blood pressure; check
heart rate and electrocardiogram for possible atrial
fibrillation; and complete a neurologic assessment—
especially noting possible changes related to stroke
and head trauma.10
Assessment for poor balance and gait can be
accomplished with the timed up-and-go test: ask the
patient to rise out of chair, walk 10 feet, turn around,
return to the chair, and sit down.11 (Remain close in
46. case the patient begins to fall.) Look for shuffling
gait, lack of arm swing, unequal shoulder or hip
height (which can indicate spinal deformity or leg
shortening), the ability to turn without support, and
the ability to stand and sit in a controlled fashion.
The timed up-and-go test should be accomplished in
20 seconds or less. Further referral is indicated if the
and may cause clinicians to miss one of the most
important symptoms of undiagnosed illness.
Delirium. In addition to medications, other pri-
mary causes of delirium include dehydration,
hypoxia, metabolic disturbances, untreated anemia,
nutritional deficiencies, and infection (especially
those of the respiratory and urinary tracts).8
Secondary causes include untreated thyroid disease,
vitamin deficiency (especially B12), and decreased
sensory input from loss of vision or hearing.
Patients who are unable to see or hear others are
often disorientated. When necessary, eyeglasses and
hearing aids are a simple intervention.
When possible, familiar routines and care can
help reorient patients to new environments. For the
older adult, sudden location changes—for example,
a move from a nursing home to a hospital—can be
confusing and trigger delirium.
If caught in time, delirium can be reversible. At
minimum, assessment should include the following
three questions that are part of the Confusion
Assessment Method:
1. Did the confusion happen rather quickly—for
47. example, since admission or the onset of illness—
and are there times during the day when the person
is more confused than at other times?
2. Is this person easily distracted and inattentive
to tasks or conversations?
3. Does the person have an altered level of con-
sciousness—is he overly alert, groggy, or stuporous?9
44 AJN ▼ October 2004 ▼ Vol. 104, No. 10
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TRY THIS
A resource for geriatric tools.
Several types of assessments are needed to determineif changes
in a patient’s health are due to a change
in health status or to normal aging. Yet while numerous
assessment tools exist, few have been either developed
for or modified to meet the norms of aging. An excellent
resource for nurses working with older adults is the “Try
This” series, sponsored by the Hartford Institute for
Geriatric Nursing. Available both in print and on the
Internet (at www.geronurseonline.org, this series is
focused on assessing common problems and symptoms
in older adults. Through “Try This,” nurses can gain
access to a wide variety of resources, including the
Beers Criteria for Potentially Inappropriate Medication
Use in the Elderly and tools used to assess mental status
or confusion (the Mini Mental State Examination or the
Confusion Assessment Method), pain or discomfort
(Checklist of Nonverbal Pain Indicators), and falling (Fall
Risk Assessment). In addition to providing the tool, “Try
This” provides directions for administration and guid-
ance on the interpretation of results.
48. Want to discuss what you’ve read in this article or other issues
related to
nurses caring for older adults? Go to
www.nursingcenter.com/ajnolderadults to
participate in a discussion forum with the
series authors and editors.
patient takes more than 30 seconds to complete the
task.
Medications should be reviewed and special note
taken of psychoactive drugs (especially sedatives),
drugs that lower blood pressure, and those that
cause hypoxia or hypoglycemia. People with
dementia or delirium are 50% more likely to fall
and thus need careful assessment and monitoring.12
Those who fall will fall again until the cause is diag-
nosed and corrected.
Dehydration is common in older adults because
decreased muscle mass means that they have less
free water, the extracellular water that predomi-
nates in muscle tissue. Additionally, the thirst
response is blunted with age—this can result in
inadequate fluid intake.13 Chronic dehydration is
more likely to occur in older adults, especially those
who are unable to hold a glass steadily, such as
nursing home patients or those with dementia.
During acute dehydration, which may result
from vomiting, diarrhea, or fever, which may cause
metabolic rates to increase, the kidneys do not con-
49. centrate urine; older adults are then at risk for fur-
ther dehydration. Noting basic parameters as
orthostatic hypotension, dryness of the oral mem-
branes, poor skin turgor, and urine color and
amount, as well as checking for elevated serum
sodium (above 145 mEq/L) and osmolarity (outside
the range of 280 to 300 mOsm/kg), can alert the
nurse to further action.
Decrease in appetite or early satiety is not always
classic anorexia but may mean other problems are
fomenting.14 In older adults, worsening of heart fail-
ure and early-onset pneumonia can present with this
symptom before any other.
Pain can change markedly with age. Like younger
adults, older adults experience both acute and
chronic pain. However, the two groups may use dif-
ferent words to describe their pain (for example,
older adults may complain of “aches” or “discom-
fort”) and older adults may have difficulty pinpoint-
ing the exact origin of pain, especially if it occurs
below the waist and is reported as “crampy.”
Furthermore, people with chronic pain may have dif-
ficulty evaluating their pain on the common 0-to-10
scale in which 0 means no pain. Commonly used
tools for assessing pain in older adults include the
visual analog scale, the verbal descriptor scale, and
the Wong–Baker FACES Pain Rating Scale.15
In people with dementia, special attention must
be paid to nonverbal cues. For example, someone
with dementia who is unable to ask for analgesia
may express pain by grimacing, moaning, crying
out, or resisting a caregiver’s attempts to move the
50. patient’s body. Additionally, peripheral and sensori-
motor neuropathy may cause people with diabetes
to be unaware of trauma to the extremities. Thus, in
both these populations, careful and frequent exam-
ination of all vague complaints of pain is necessary.
Such examination may entail a review of the
patient’s history and records for potential causes of
pain, an assessment of current pain, and a review of
all medications in the patient’s regimen. The
patient’s beliefs about use of pain medication should
be examined—especially myths about addiction—
and the patient’s family should be contacted for fur-
ther information.16
Loss of functional ability can be significant in
active people and in those with extremely limited
mobility. Fatigue and decline in activity may signal
anemia, thyroid disease, infection, or cardiovascular
or pulmonary insufficiency. While numerous assess-
ments exist to test ability, both the Katz Index of
Activities of Daily Living and the Barthel Index
were developed specifically for older adults.
However, the most effective way to monitor func-
tion is to establish a baseline by observing the
patient as he performs his usual routines and then
assess function regularly, especially during a decline
in health. Timely referral to rehabilitation programs
may allow older adults to regain prior capacity—
before the onset of permanent decline.
Dizziness is a common complaint. As people
age, they are more likely to report sensations such
as vertigo, lightheadedness, disequilibrium, or a
vague sense of dizziness. Careful questioning about
51. [email protected] AJN ▼ October 2004 ▼ Vol. 104, No. 10 45
COCKCROFT–GAULT EQUATION FOR
CALCULATING CREATININE CLEARANCE
Creatinine clearance* � (140 � age) � weight (kg)
serum creatinine (mg/dL) � 72 (� 0.85 for women)
* Special considerations: For patients over 90 years old, use age
90. For obese patients, use the
ideal body weight:
Men = 50 kg � 2.3 kg for every inch over 5 feet
Women = 45.5 kg � 2.3 kg for over every inch over 5 feet
Cockcroft DW, Gault MH. Nephron 1976;16(1):31- 41
Nursing assessments include checking for irregular
pulses, measuring orthostatic blood pressure,
reviewing the patient’s most recent electrocardio-
gram, and asking about hearing loss or ringing in the
ears. Neurologic assessments are also required. Note
balance as the patient walks heel to toe, observing if
he begins to fall to one side or grabs on to objects for
stability. Note his ability to perceive position (for
example, can he close his eyes and still correctly
detect direction as the nurse moves his big toe up and
down?). Watch for swaying when the patient is
standing with his eyes closed. Finally, measure
the circumstances surrounding the episode is
required: Was the patient getting up suddenly, lean-
ing his head backward, sitting still, or moving?
Questioning about the sensation itself is also
52. important: Did the patient perceive the room spin-
ning? Was he faint or woozy? Was he unsteady or
off balance?
Dizziness can be a symptom of anemia, arrhyth-
mia, depression, infection, ear disease, acute myocar-
dial infarction, eye problems, stroke, cerebral
tumors, vasovagal response, or cerumen impaction
in the ear. It can also be a sign of drug toxicity.17
46 AJN ▼ October 2004 ▼ Vol. 104, No. 10
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TABLE 1. AGING OF THE BODY’S SYSTEMS
Body System Physiologic Changes Expected Signs or Symptoms
Skin • Loss of subcutaneous tissue and thinning
of dermis
• Underlying tissue more fragile; inabili-
ty to respond to heat or cold quickly;
proneness to heat stroke; loss of mois-
ture; wrinkling
Sensory • Loss of lid elasticity
• Ocular changes in cornea, iris, pupil,
lens
• Auditory canal narrows
• Calcification of ossicles
• Changes in organ of Corti
• Olfactory bulb and cells decrease
• Eyelids drop or turn inward
• Increased astigmatism; need for more
53. light; glare problematic; need for eye-
glasses
• Cataracts
• Increased cerumen
• Hearing loss
• Impaired sound transmission, tinnitus
• Inability to discriminate odors
Cardiovascular • Decreased stress response
• Stiffer valves
• Conductivity altered
• Vessels less elastic
• Diminished cardiac output
• Diastolic murmurs
• More ectopic beats; less ability to
respond to changes in blood pressure
• Poorer perfusion to vital organs with
resulting hypoxia; varicosities; peripher-
al pulses not always palpable
Pulmonary • Enlargement and rigidity of chest wall
• Airway collapse
• Poorer expansion with less efficient
exchange; shallower breathing; less
effective cough
• Oxygen exchange less efficient espe-
cially under stress
Gastrointestinal • Increase in occurrence of hiatal hernia
and decrease in intraabdominal
54. strength
• Reduced gastric acid
• Slower neural transmission
• Weakening of intestinal walls
• Reflux
• Peptic ulcers
• Vitamin deficiency
• Constipation and incontinence
• Diverticulosis
extraocular movements by asking the patient to
watch as you slowly outline the letter “H,” noting
any rapid back-and-forth eye movements as he fol-
lows your hand.
Incontinence isn’t unique to older adults, but
new-onset urinary incontinence should always be
investigated. In older adults incontinence often
occurs as a result of a urinary tract infection, limited
mobility, or metabolic problems such as hyper-
glycemia or hypercalcemia. Other causes include the
use of medications such as diuretics or sedatives, the
latter of which can inhibit the person’s ability to rec-
ognize the need to use the toilet and slow his move-
ment toward the bathroom. While many techniques
can be used to rehabilitate people with urge or stress
urinary incontinence or urinary retention, these
reversible causes must be investigated first.18 A dip
stick urine test to look for the presence of the
nitrites and blood usually found during infection
can provide excellent clues for further workup.19
55. PRESENTATION OF DISEASE
Infection. It is believed that immunity deteriorates
with age as a result of decreasing T lymphocyte
[email protected] AJN ▼ October 2004 ▼ Vol. 104, No. 10 47
Ebersole P. Age-related changes. In: Ebersole P, et al., editors.
Toward healthy aging. Human needs and nursing responses.
Philadelphia: Mosby; 2004. p. 74-80.
Renal • Decrease in blood flow, glomeruli,
renin, and filtration
• Increased creatinine clearance; loss
of ability to concentrate urine and
conserve water; poor response to
stress
Musculoskeletal • Shrinking vertebral discs, loss of bone mass
• Muscle atrophy
• Loss of height by 1.5 to 3 in.; fracture
more common
• Decrease in strength and stamina;
atrophy
Neurologic • Diminished stage 3–4 (deep) sleep
• Decreased proprioception
• Altered pain sensation
• Tactile sense decreases
• Sleep disorders, especially in different
environments (hospital)
56. • Difficulty in changing position or
achieving balance
• Decreased perception of pain
• Loss of sensation in extremities
Immune • Decrease in thymus mass and
production
• Increase in immunoglobulins
• Decline in cell-mediated immunity; reac-
tivation of disease (tuberculosis, herpes)
• Autoimmune response not associated with
disease
Endocrine • Loss of sensitivity to insulin
• Diminished sex hormones
• Blood glucose does not return to normal
as quickly
• Benign prostatic hyperplasia; testicular
firmness; vaginal dryness and atrophy;
longer time to orgasm
Body System Physiologic Changes Expected Signs or Symptoms
function.20 With age, the thymus gland decreases in
size and function. As a result, the effectiveness of
the T lymphocyte response to antigens decreases.
Rates of infection rise steadily with age, and mor-
tality rates are sometimes two to three times higher
57. for the same diseases seen in younger people. There
is also an increase in certain cancers and autoim-
mune diseases with aging. Because of lower basal
metabolic rates, older adults have lower core tem-
peratures. Thus, a patient with a normal tempera-
ture or a low-grade fever may actually be
experiencing a significant temperature hike.
Additionally, with age, the body’s ability to trigger
an inflammatory response to pathogens slows,
making temperature an imprecise measure of the
severity of infection. When assessing for infection,
it’s critical to have an accurate baseline temperature
and to note any recent changes such as confusion
or decreased activity.
Presentation. Because the symptoms of infections
change with age—for example, fever and chills are
replaced with confusion or decreased functional
ability—they often go undetected in older adults
until the infection has reached an acute stage.
Additionally, many older adults who use non-
steroidal antiinflammatory drugs for painful muscu-
loskeletal conditions have their inflammatory
response altered, so at intake nurses should always
question patients about recent use of antipyretic
medications. The following list describes possible
presentations of the infections most commonly
occurring in older adults:
• pneumonia—increased respiratory rate with
decreased appetite and functioning
• urinary tract infections—incontinence, increased
confusion and falls
Skin infections are often missed in older adults,
58. who may be difficult to undress or move from a
wheelchair. Cellulitis can occur in people with vas-
cular disease; early signs may be missed in people
with chronic dependent edema.
Alterations in gastrointestinal status have many
causes, including low-level dehydration, slower
peristalsis, chronic neuromuscular disease, or even
lack of mobility related to osteoarthritis (which can
make the older adult prone to constipation). Other
causes of gastrointestinal distress may present in the
older adult as follows:
• Upper or lower GI bleeding may present insidi-
ously with signs of dehydration and crampy
abdominal pain that’s difficult to localize.
• GI obstruction can present without the usual
boardlike abdomen, but instead with cramps,
dehydration, stringy stool or diarrhea, and vague
complaints of feeling unwell.
• Diverticulosis may present with diffuse pain and
a low-grade temperature that signal inflamma-
tion, infection, or even perforation.
48 AJN ▼ October 2004 ▼ Vol. 104, No. 10
http://www.nursingcenter.com
TIPS FOR NURSES BY
HEALTH CARE SETTING
Hospital nurses
• Confusion is not inevitable. Look for neurologic
events or new medication.
59. • Many hospitalized older adults suffer from chronic
dehydration accelerated by acute illness.
• Not all older adults have high fevers with infection.
Other symptoms can include increased respiratory
rate, falls, incontinence, or confusion.
Nursing home nurses
• Pain is undertreated in older adults with dementia.
Look for nonverbal cues such as grimacing or
resistance to care.
• Decline in functional ability (even minor declines,
such as the inability to sit upright in a chair) may
be a signal of new illness.
• Residents with less muscle mass—both the frail and
the obese—are at much higher risk for toxicity from
protein-binding drugs such as phenytoin (Dilantin
and others) and warfarin (Coumadin and others).
Ambulatory care nurses
• Complaints of fatigue or decreased ability to do
usual activities may be signs of anemia, thyroid
problems, depression, or neurologic and cardiac
problems.
• Severe gastrointestinal problems in older adults
don’t always present with the acute symptoms seen
in younger patients. Ask about constipation,
crampy sensations, and changes in bowel habits.
• Older adults reporting increased dyspnea and confu-
sion, especially those with a cardiac history, should
60. be sent to the ED; these are the most common presen-
tation of myocardial infarction in this population.
• Depression is common among older adults with
chronic illnesses. Watch for lack of interest in for-
mer activities, significant personal losses, or
changes in role or home life.
Home care nurses
• Falls should be investigated further, focusing on
balance, gait, and neurologic issues.
• Older adults being treated for late-stage heart dis-
ease should be monitored for loss of appetite as
an early symptom of impending failure.
• Drug–drug interactions in older patients who are
seeing more than one provider and taking multiple
medications are common. Watch for signs.
Assessment. When assessing for alterations in
gastrointestinal status, first observe the contour of
the abdomen, looking for old scars that might indi-
cate adhesions. Then, using the stethoscope, listen
in all four abdominal quadrants for the presence of
bowel sounds. Percussion of the abdomen helps
nurses determine whether the bowel is filled with
feces or air. Special attention should be paid to any
bruits or masses in older adults with poorly con-
trolled hypertension; these may signal an abdominal
aortic aneurysm and should be confirmed with an
ultrasound or computed tomographic (CT) scan.
Finally, light followed by deep palpation will help
61. isolate painful areas, determine the existence of
masses, and identify distention of the bladder. A
patient’s report of blood in the stool or changes in
stool color may be unreliable since the patient may
be unable to clearly see the toilet contents.
Appendicitis. Although often considered a dis-
ease of young adulthood, appendicitis also occurs in
older adults. The rate of morbidity and mortality
with appendicitis increases with age from 1% in the
general population to 70% in older adults.21 Among
older adults, appendicitis is often misdiagnosed as
bowel obstruction and surgical treatment is delayed,
resulting in a higher rate of perforation. The four
classic symptoms—right lower-quadrant pain, ele-
vated white blood counts, fever, and anorexia—are
still present and quite predictive but are often
missed because health care providers may not sus-
pect appendicitis in older patients. Thorough
abdominal examination, blood work, careful evalu-
ation of reports of pain and decline in appetite, and
evaluation using abdominal and pelvic CT scans
can reduce the potentially devastating effects.
Cardiac disease. In the most acute insult,
myocardial infarction, the classic symptom is not
crushing chest pain and diaphoresis, but sudden
onset of dyspnea often accompanied by anxiety and
confusion. Recognition of these signs and symp-
toms can result in early detection and treatment.
The damaged heart muscle is unable to adequately
perfuse, which causes associated symptoms such as
confusion (caused by decreased cerebral profusion)
or a drop in urine output (caused by decreased renal
perfusion). The absence of ischemic pain is particu-
larly evident among persons with long-standing
62. angina and those with poorly controlled diabetes.
Heart failure. The beginning signs of worsening
heart failure may be hard to detect in an inactive
older adult with dependent edema. Often, the only
changes noted may be a decreased appetite, weight
gain of 2 to 3 lbs., and complaints of poor sleep.
Teaching patients and caregivers these simple signs
could ensure appropriate treatment and help
patients to avoid future hospitalizations.
Nurses need to be cautious about the aggressive
administration of IV fluids delivered to people with
heart disease and long-standing, poorly controlled
hypertension; they may be at high risk for heart fail-
ure. Aggressive treatment is required for those iden-
tified as high risk. Critical observations include
sudden onset of confusion or increased anxiety,
increase in respiratory rate, widening pulse pres-
sure, weight change from baseline, overwhelming
fatigue, and anorexia.
Type 2 diabetes. As blood glucose rises, the older
adult may not experience the three Ps: polyuria,
polydipsia, and polyphagia. Instead, the patient is
more likely to become dehydrated, confused,
develop incontinence related to glycosuria, and later
develop a wasting disorder with weight loss instead
of gain. Confusion is an early symptom of hypo-
glycemia. If older adults are treated with certain
oral hypoglycemic agents that stimulate insulin pro-
duction (such as sustained-release glipizide
[Glucotrol XL and others]), their risk for acute
hypoglycemia increases because they are less able to
create and store glycogen for transformation to
63. blood glucose when blood levels drop. This is espe-
cially problematic if the person lives alone and has
no one to remind him to eat during illness or other
times of stress. The American Diabetes Association
recommends that people in the following categories
be screened for diabetes: those with a family history
of the disease; those with a body mass index greater
than 25; those with hypertension or elevated lipids;
members of high-risk racial or ethnic groups such as
African Americans, Latinos, Native Americans,
Asian Americans, or Pacific Islanders; and those
with a history of vascular disease with a fasting
plasma glucose level of greater than 126 mg/dL.22
Thyroid disease. Fatigue and tremor, two of the
most common symptoms of thyroid problems, may
be missed or absent in old age. The gland itself may
be hard to palpate as it slips lower and deeper into
the neck. Instead, hyperthyroidism presenting in old
age is often seen with new onset atrial fibrillation,
weight loss, proximal muscle weakness, and confu-
[email protected] AJN ▼ October 2004 ▼ Vol. 104, No. 10 49
THE ABSENCE OF ISCHEMIC PAIN IS
PARTICULARLY EVIDENT AMONG
PERSONS WITH LONG-STANDING
ANGINA AND THOSE WITH POORLY
CONTROLLED DIABETES.
64. Because the complaints of younger and older
adults may be different, it’s important to use an
instrument specific to assessing depression in older
adults. One such instrument is the Geriatric
Depression Scale, which is available at www.
hartfordign.org/resources/education/tryThis.html.
Depression scales developed specifically for older
adults don’t focus on somatic complaints or fatigue,
as these may be manifestations of chronic illness.
Older adults often present with confusion, lack of
interest in life, or unwillingness to participate in the
examination (providing answers such as “Why are
you bothering me?”). Asking the questions, “Are
you sad or blue?” and “Have you stopped doing
things that once gave you pleasure?” are simple
screening questions to detect depression. Nurses
must ask specifically about plans for self-harm
when self-destructive thoughts are stated. ▼
REFERENCES
1. National Institute on Aging. Research for a new age. 1993.
http://www.niapublications.org/ pubs/research/index.asp.
2. Ebersole P. Age-related changes. In: Ebersole P, et al.,
editors.
Toward healthy aging. Human needs and nursing responses.
Philadelphia: Mosby; 2004. p. 79-108.
3. Siegel L. Are telomeres the key to aging and cancer? 2004.
http://gslc.genetics.utah.edu/ features/telomeres.
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ibmsscience.org/general/ageing.htm.
5. Sohal RS. Role of oxidative stress and protein oxidation in
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6. Flacker JM. What is a geriatric syndrome anyway? J Am
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7. Gleason OC. Delirium. Am Fam Physician 2003;67(5):
1027-34.
8. Foreman MD, et al. Delirium in elderly patients: an
overview of the state of the science. J Gerontol Nurs
2001;27(4):12-20.
9. Inouye SK, et al. Clarifying confusion: the confusion assess-
ment method. A new method for detection of delirium. Ann
Intern Med 1990;113(12):941-8.
10. Resnick. Preventing falls in acute care. In: Mezey M, et al.,
editors. Geriatric nursing protocols for best practice. New
York: Springer; 2003. p. 141-64.
11. Bischoff HA, et al. Identifying a cut-off point for normal
mobility: a comparison of the timed ‘up and go’ test in com-
munity-dwelling and institutionalised elderly women. Age
Ageing 2003;32(3):315-20.
12. Nowalk MP, et al. A randomized trial of exercise programs
among older individuals living in two long-term care facili-
ties: the FallsFREE program. J Am Geriatr Soc
2001;49(7):859-65.
13. Hodgkinson B, et al. Maintaining oral hydration in older
adults: a systematic review. Int J Nurs Pract 2003;9(3):S19-28.
14. van Staveren WA, et al. Regulation of appetite in frail per-
sons. Clin Geriatr Med 2002;18(4):675-84.
66. 15. Herr K. Chronic pain: challenges and assessment strategies.
J Gerontol Nurs 2002;28(1):20-7; quiz 54-5.
16. Horgas A, McLennon S. Pain management. In: Ebersole P,
et al., editors. Toward healthy aging. Human needs and
nursing responses. Philadelphia: Mosby; 2004. p. 229-50.
sion, while hypothyroidism may have few, if any,
symptoms.23 Many older adults have subclinical
thyroid disease and may suffer cardiac disease and
osteoporosis before treatment is initiated; nurses
should carefully assess complaints of fatigue in all
older adults.
Assessment. To assess endocrine problems, the
thyroid can be palpated in the neck as the trachea is
stabilized and the person is asked to turn his head.
Thyroid stimulating hormone remains the preferred
indicator of thyroid disease (the normal range for
adults is 0.4 to 4 µIU/mL) and needs to be closely
monitored in older adults taking amiodarone
(Cardarone and others) for heart disease.24
Depression is the most commonly occurring men-
tal health problem for older adults, especially in
those with chronic illness and those living in institu-
tions.25 As the rate of suicides is highest in older
white men, early assessment and treatment of
depression is paramount.26 However, many older
adults avoid complaining of feeling sad or depressed,
which can make it difficult for health care practition-
ers to recognize this problem in their patients.27
Additionally, the societal expectation that older
adults are tired, complain, and have little interest in
life may disguise the most common symptoms of
67. depression: fatigue, somatic symptoms that don’t
seem to have an origin in pathology, and a decrease
in activities the person formerly enjoyed. Failure to
recognize that most older adults find satisfaction and
joy in life can deprive patients of treatment that
could vastly improve the quality of their lives.
Assessment. Kurlowicz recommends screening
for depression in the following high-risk groups:
alcohol or substance abusers; people with dementia,
stroke, cancer, arthritis, hip fracture, myocardial
infarction, chronic lung disease, or Parkinson dis-
ease; those suffering from functional disability, espe-
cially new onset; widows or widowers; caregivers;
and those who are isolated or lacking social sup-
port.28 Furthermore, certain medications, especially
digitalis (Digoxin and others), propranolol (Inderal
and others), and benzodiazepines, are associated
with depression.29
50 AJN ▼ October 2004 ▼ Vol. 104, No. 10
http://www.nursingcenter.com
Complete the CE test for this article by
using the mail-in form available in this
issue or visit NursingCenter.com’s
“CE Connection” to take the test and find
other CE activities and “My CE Planner.”
THE 8TH ANNUAL NURSES IMPROVING
CARE FOR HEALTHSYSTEM ELDERS
LEADERSHIP CONFERENCE
January 31 to February 1, 2005
Marriot Financial Center Hotel,
New York City
68. For more information, visit
www.nicheprogram.org.
17. Eaton DA, Roland PS. Dizziness in the older adult, part 1.
Evaluation and general treatment strategies. Geriatrics
2003;58(4):28-30, 3-6.
18. Wyman JF. Treatment of urinary incontinence in men and
older women: the evidence shows the efficacy of a variety of
techniques. Am J Nurs 2003;(Suppl):26-35.
19. Thurlow KL. Infections in the elderly: part 2. Emerg Med
Serv 2002;31(4):44.
20. Aspinall R. Age-related changes in the function of T cells.
Microsc Res Tech 2003;62(6):508-13.
21. Storm-Dickerson TL, Horattas MC. What have we learned
over the past 20 years about appendicitis in the elderly? Am
J Surg 2003;185(3):198-201.
22. Standards of medical care in diabetes. Diabetes Care
2004;27(Suppl 1):S15-35.
23. Margolius S, Reed R. Thyroid disease. In: Ham R, et al.,
editors. Primary care geriatrics. A care-based approach. St.
Louis, MO: Mosby; 2002. p. 517-24.
24. Demers LM, Spencer CA. Laboratory medicine practice
guidelines: laboratory support for the diagnosis and moni-
toring of thyroid disease. Clin Endocrinol (Oxf)
2003;58(2):138-40.
69. 25. Birrer RB, Vemuri SP. Depression in later life: a diagnostic
and therapeutic challenge. Am Fam Physician
2004;69(10):2375-82.
26. Chima F. Elderly suicidality. Human behavior and social
environment perspective. J Human Behav Soc Environ
2002;6(4):21-6.
27. Nelson J, Battista D. Diagnosis and treatment of late-life
depression. Clin Nurse Spec 2002:69-71.
28. Kurlowicz L. Depression in older adults. In: Mezey M, et
al.,
editors. Geriatric nursing protocols for best practice. New
York: Springer; 2003. p. 185-205
29. Blazer DG. Depression in late life: review and commentary.
J Gerontol A Biol Sci Med Sci 2003;58(3):249-65.
30. Willlams CM. Using medications appropriately in older
adults. Am Fam Physician 2002;66(10):1917-24.
31. Family Practice Notebook. Lab markers of malnutrition.
2000. http://www.fpnotebook.com/ PHA48.htm.
32. Payne K. Total serum protein. 2004. http://my.webmd.com/
hw/health_guide_atoz/ hw43614.asp.
33. Veterans Health Administration, Department of Defense.
VHA/DoD clinical practice guideline for the management of
chronic kidney disease and pre-ESRD in the primary care
setting. Washington, DC: Department of Veterans’ Affairs;
2001.
[email protected] AJN ▼ October 2004 ▼ Vol. 104, No. 10 51
70. GENERAL PURPOSE: To present registered professional
nurses with an overview of the aging process and
the factors that produce altered presentations of sev-
eral illnesses in older adults.
LEARNING OBJECTIVES: After reading this article and
taking the test on the next page, you will be able to
• discuss the pathophysiology of the aging
process and the ways it predisposes older
adults to illness.
• describe the assessment process for older adults, as
well as the possible causes of abnormal findings.
• list specific examples of the altered presentation
of common disorders in older adults.
To earn continuing education (CE) credit, follow these
instructions:
1. After reading this article, darken the appropriate boxes
(numbers 1–17) on the answer card between pages TK
and TK (or a photocopy). Each question has only one
correct answer.
2. Complete the registration information (Box A) and help
us evaluate this offering (Box C).*
3. Send the card with your registration fee to: Continuing
Education Department, Lippincott Williams & Wilkins, 333
Seventh Avenue, 19th Floor, New York, NY 10001.
4. Your registration fee for this offering is $13.95. If you take
two or more tests in any nursing journal published by
Lippincott Williams & Wilkins and send in your answers to
all tests together, you may deduct $0.75 from the price of
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receives your answer card, you’ll be notified of your test
results. A passing score for this test is 12 correct answers
(77%). If you pass, Lippincott Williams & Wilkins will
send you a CE certificate indicating the number of
contact hours you’ve earned. If you fail, Lippincott
Williams & Wilkins gives you the option of taking the
test again at no additional cost. All answer cards for this
test on Presentation of Illness in Older Adults must be received
by October 31, 2006.
This continuing education activity for 2 contact hours
is provided by Lippincott Williams & Wilkins, which is
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Center’s Commission on Accreditation and by the
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approved provider of CNE in Alabama, Florida, and
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#ABNP0114, FL #FBN2454, IA #75. All of its home
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*In accordance with Iowa Board of Nursing administrative
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