Kristen Mauk

This is my dog. Her name is Grace. We fondly call her Gracie.

Gracie is a miniature pinscher, born just over 9 years ago, the last of a six-puppy litter. She was barely 3 inches long at birth and a third the size of the other puppies. We doubted she would survive. Her mother rejected her and tried to throw her out of “the nest” because she was different than the other puppies.

But my children and I believed in Gracie’s survival. We fed her by hand with an eyedropper as we cradled her in our palms, and we gave her the love and nurture she didn’t get from her own family of dogs. I had to lay her mother on my lap so that Gracie could be nursed apart from the others. When she was too weak to nurse, the kids and I took shifts to feed her around the clock and speak encouraging words of survival to her. Soon she became the strongest and most dominant of the pack, although still the smallest. She could fend off her five littermates from the food bowl with a fierce growl and scary glance. And Gracie repaid our faith in her will to live by returning the care and comfort she received from us with a lifetime of love and companionship.

Now that she is an older adult dog, she shows those signs of aging that we all do: gray hair, hearing loss, cataracts, stiff joints, and some excess weight around the middle. But like so many of us Baby Boomer humans, Gracie has the heart and soul of her younger years. She will still chase a chipmunk, but no longer catches it. She can still jump around with excitement, but then promptly falls asleep on the couch. Even in her old age, she continues to teach us about another kind of grace.

When I return from a business trip, Gracie is the first to greet me. Long before my husband or kids make it to the door, she hears my footsteps and comes running. You would think I was the most important person on earth as she jumps and whines and licks me, climbing in my lap for some affection. She makes me feel like a queen. It doesn’t matter to Gracie if I am in a grumpy mood, if I’m overweight, or if my hair is gray. She doesn’t care if I’m smart or not, or if others find me attractive. I am her person! She loves me the same in the morning, noon, or night and she never holds a grudge. In fact, I think that my dog seems to know more about unconditional love than many people do. She doesn’t hold my faults against me and she loves me just the way I am. She always shows it no matter what else has happened in the day. Gracie is the one at my feet in every room of the house. She sleeps next to me when I watch TV. She follows me everywhere. She is always at the door to protect me from strangers. She would give her life for mine in an instant if she could, and without a thought for herself. I sometimes find myself wishing that I had her strength of character.

It is a wonder to me that an ordinary, common, little runt of a dog without the powers of human reasoning could possess qualities that we so seldom see in people. The judgment and unforgiveness of others, sometimes even among our own families, is outshone by the loyalty and companionship that little Grace gives me every day.

So, maybe today we can learn a lesson from the simplest of God’s creatures. Show your enthusiasm for life and each other. Be a loyal companion. Take time to show affection. Miss each other terribly when you are apart. Be happy when you are together again. Forget past mistakes and harsh words. Practice forgiveness. And above all, love unconditionally.

Background

Urinary tract infections (UTIs), also called cystitis (inflammation of the bladder), are common among older adults and are more frequent in women. They are a primary cause of urinary incontinence and delirium. Catheter-associated urinary tract infections (CAUTIs) are more common among older adults (Fakih et al., 2012) and is mainly attributed to the use of indwelling urinary catheters. Many indwelling catheters are thought to be unnecessary (Cochran, 2007) and one study noted that physicians were often not aware of the purpose for which their patients had a catheter inserted (Saint, Meddings, Calfee, Kowlaski, & Krein, 2009). UTIs have been show to increase morbidity and mortality, length of hospital stay, and cost of hospitalization (Kleinpell, Munro, & Giuliano, 2008). CAUTI is considered preventable and is not reimbursed by Medicare. Therefore, hospitals will largely assume the financial costs for preventable infections of this type.

Risk factors/Signs and symptoms

Several risk factors are associated with UTIs in general. These include being female, having an indwelling urinary catheter, the presence of urological diseases, and hormonal changes associated with menopause in women. Signs and symptoms of UTIs include urinary frequency and burning or stinging felt during voiding. Pain may be felt above the pubic bone, and a strong urge to void but with small amounts of urine expelled. The most significant risk factor for CAUTI is prolonged use of an indwelling catheter. In hospital-acquired UTIs, 75% are associated with the use of an indwelling catheter (CDC, 2012). In women, signs and symptoms of CAUTI may be more severe than those reported by women by patients in the community who do not have an indwelling catheter. Lethargy, malaise, onset or worsened fever, flank pain, and altered mental status have been associated with CAUTI (Hooton et al., 2010).

Diagnosis

A thorough assessment should be done of the patient’s urinary output, including amounts, color, odor, appearance, frequency of voiding, urgency, and episodes of incontinence. A urine specimen should be obtained if UTI is suspected. Laboratory results will show the type of organism causing the infection, and the sensitivity will tell what medication the organism is susceptible to. These results should be reported promptly to the physician or nurse practitioner caring for the patient and so that a diagnosis and treatment plan can be made.

Treatments

Prevention of UTIs is considered a primary nursing strategy. Elderly female patients can be instructed to make lifestyle modifications such as: increasing their fluid intake; emptying the bladder after sexual intercourse; practicing good perineal hygiene, including wiping front to back after toileting; getting enough sleep; and avoiding stress (PubMed Health, 2011). Although many of these common sense strategies are recommended by primary care providers, there is a lack of scientific evidence to support some of them. Many UTIs will clear up on their own, particularly if the person increases oral fluid intake during early symptoms. However, with many older adults, antibiotic treatment may be needed. In general, a course of three 3 days for healthy adults is thought to be sufficient, but for more resistant bacteria, a longer course more than five 5 days may be needed (PubMed Health, 2011). For those with repeated or chronic UTIs, a low dose of antibiotics taken for 6– 12 months may be indicated (Hooton et al., 2010). If the underlying cause is CAUTI, treatment will be more aggressive. Monitor the patient’s temperature at least every 24 hours (Carpenito, 2013). Encourage fluids. Evaluate the necessity of continuing an indwelling catheter if one is in place.

Alternatives to indwelling catheters should be considered for appropriate patients. Intermittent catheterization, if appropriate, is preferred over indwelling catheter use, especially for long- term maintenance of bladder management (CDC, 2009; Hooton et al., 2010). Condom catheters may be an appropriate choice for some males. If an indwelling urinary catheter is necessary, the catheter should be removed as soon as possible, per the physician or nurse practitioner’s orders, to reduce the risk of CAUTI.

Adapted from Mauk, K. L., Hanson, P., & Hain, D. (2014). Review of the management of common illnesses, diseases, or health conditions. In K. L. Mauk’s (Ed.) Gerontological Nursing: Competencies for Care. Burlington, MA: Jones and Bartlett Publishers. Used with permission.

Save

Background

Similar to hip replacement, knee replacement is done when a person is experiencing decreased range of motion, trouble walking or climbing stairs, and increased degeneration of the joint so as to impair quality of life. This most often occurs as a result of arthritis.

Treatment

Total knee replacement (TKR) surgery involves resurfacing or removing the distal portion of the femur that articulates with the end of the shin bone. The prosthesis consists of metal and plastic or similar materials that are cemented onto the newly resurfaced areas of the articulating bones. Although often done under general anesthetic, this surgery can also be performed under spinal anesthesia. Sometimes blood loss is significant, so patients may be asked to donate their own blood ahead of time to be given back to them in the event it is needed. In addition, a growing trend is toward bilateral knee replacement in those persons requiring both knees to be surgically repaired. The benefits of this are the one-time operative anesthetic and room costs, and many physicians feel recovery from bilateral replacement is similar to single replacement. However, the pain and lack of mobility, as well as the significant increase in the assistance needed after surgery when a bilateral replacement is done, may make this less than ideal for older patients. Surgical procedures for TKR have not evolved quite as rapidly as total hip arthroplasty.

Discomfort after knee surgery is generally severe in the first few days. Complications after surgery may occur, including pain, infection, and blood clots. Patients may use cold packs on the operative area and take pain and sleeping medications as ordered. In addition, alternative therapies such as guided imagery have been shown to help with pain management (Posadzi & Ernst, 2011). Many joint replacement patients feel a loss of control and independence.

Therapy will begin immediately in the acute care hospital. Although weight bearing does not usually occur until 24 hours after surgery, sitting in a chair and using a continuous passive motion machine (CPM) (if ordered), will ease recovery. The use of a CPM is generally based on the surgeon’s preference. There is research to support it, as well as studies indicating that walking soon after surgery has an equal effect and makes the CPM unnecessary. However, in cases of an older person who may not have the mobility skills initially after surgery that a younger person would, a CPM may be beneficial to keep the joint flexible and decrease pain.

Dr. Zann (2005) indicated that “patients undergoing total knee replacement do not achieve their maximum improvement until 2–4 years” (p. 1). This is attributed to the lack of muscular structures that surround and protect the knee and the need for the ligaments and tendons to adapt to the indwelling prosthesis. Recovery times vary and depend upon a number of variables, including the patient’s overall health, age, other preexisting health issues, and motivation. Patients report that the new knee joint never feels normal even years after the surgery, but that they experience an increase in function and generally much less pain than before.

Patients should be educated about signs and symptoms of infection, care of the surgical site (if staples are still present), pain management, and expectations for recovery. A range of motion from 0–90 degrees is the very minimum needed for normal functioning. Normal knee flexion is 140 degrees, but few older persons would get this amount of flexion after surgery, and may not have had full flexion even prior to the operation. After discharge, a walker is usually used in the first few weeks, followed by light activities 6 weeks after surgery. In addition, the patient’s spouse may experience feelings of being overwhelmed due to role transitions that occur after surgery and during the recovery period (Walker, 2012 ). Newer knee prosthetics are still going strong for the majority of patients 15 years after surgery.