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Discussion: Changes in Sites of Care

Since the culture and practices of care settings are
inherently different, changes in sites of care are often difficult for
geriatric patients. Efforts should be made to limit changes to only those necessary;
however, sometimes a patient’s situation might require multiple changes in
sites of care. When selecting sites of care, such as home, assisted living,
rehabilitation facilities, and hospitals, many factors must be considered by
patients, their families, and their health care providers. Health status,
ability to perform self-care, financial limitations, and patient preferences
are all factors that might influence a patient’s site placement. As an advanced
practice nurse who recommends sites of care and facilitates changes, you must
evaluate factors and consider sites that limit the impact of these changes on
geriatric patients.

To prepare:

Review this week’s media presentation, as well as Chapters 3
and 8 of the Resnick text.

Reflect on your personal experiences, observations, and/or
clinical practices from the last 5 years. Select a case from the last 5 years
that involves an elderly patient who has been in two different sites of care
such as home, assisted living, hospital, etc.

Note: When referring to your patient, make sure to use a
pseudonym or other false form of identification. This is to ensure the privacy
and protection of the patient.

Reflect on issues that occurred because of the change in the
patient’s sites of care. Think about the impact of differences in the settings
themselves, inherent cultures of the settings, and ethical practices of these
sites on the patient.

Consider whether the patient had an advanced directive in
place at the time of the change in sites of care. Reflect on whether any
difficult treatment decisions had to be made as a result.

Think about the impact of financial issues on site placement
and treatment decisions.

By Day 6

Respond to at least two of your colleagues on two different
days in one or more of the following ways:

Suggest community resources that may assist with related
cases in the future.

Recommend appropriate alternative site placements for your
colleagues’ patients based on your geographic location.

Provide insights on policy implications of your colleagues’
cases (i.e., Medicare, Medicaid, Veteran’s Affairs, etc.).

Week 2 discussion

Discussion: Assessment Tools

As geriatric patients age, their health and functional
stability may decline resulting in the inability to perform basic activities of
daily living. In your role as the advanced practice nurse, you must assess
whether the needs of these aging patients are being met. Comprehensive
geriatric assessments are used to determine whether these patients have
developed or are at risk of developing age-related changes that interfere with
their functional status. Since the health status and living situation of
geriatric patients often differ, there are a variety of assessment tools that
can be used to evaluate wellness and functional ability.

For this Discussion, consider which assessment tools would
be appropriate for the patients in the following three case studies:

Case Study 1

Mr. Smith, age 77, reports for an annual physical
examination. He says he is doing well. His only known problem is
osteoarthritis. He also requests a flu shot. He takes no medications other than
Tylenol for arthritis pain. When he walks into the exam room, you notice that
he is using a straight cane in his right hand. When you ask about the cane, he
says he began using the cane because the pain in his right hip had increased
significantly over the past 6 months.

Case Study 2

Mr. Jones, a 68-year-old man, was referred to your office
for a hearing evaluation. He continues to work in a printing company, although
he works only part-time. He has worked at the printing company for the past 35
years. He complains that he cannot hear much of the dialogue on the television.
He is accompanied by his wife, who states that her husband cannot hear her at
home. He has no history of dizziness, tinnitus, or vertigo. He has had cerumen
impactions removed from both ears in the past. Overall, his medical history is
quite benign. His only medications are aspirin 81 mg daily, a multivitamin
daily, and occasional ibuprofen for back pain

Case Study 3

Mrs. Roberts, an 83-year-old widow, is brought to the office
by her daughter. The daughter claims that her mother seems to be depressed.
There is a history of depression approximately five years ago, shortly after
Mrs. Roberts’ husband died. At that time, she was successfully treated with
antidepressants. Currently, the daughter states that her mother’s memory for
appointments and events has declined severely, and she can no longer drive
because she does not remember the route to the store or other familiar places.
The daughter also noted that her mother’s house seemed very disorganized and
dirty, there was a limited amount of food in the kitchen, and the checkbook had
not been balanced for several months. Mrs. Roberts appears slightly disheveled,
she has a flat affect, and she does not maintain eye contact during your
interview.

To prepare:

Review the Rosen and Reuben article in this week’s Learning
Resources. Consider how assessment tools are used to evaluate patients.

Select one of the three case studies. Based on the provided
information, think about a possible patient evaluation plan. As part of your
evaluation planning, consider where the evaluation would take place, whether
any other professionals or family members should be present, appropriate
assessment tools and guidelines, and any other relevant information you may
wish to address.

Consider whether the assessment tool you identified was
validated for use with this specific patient population and if this poses
issues. Think about additional factors that might present issues when
performing assessments, such as language, education, prosthetics, missing limbs,
etc.

Week 3 discussion

Discussion: Models of Interdisciplinary Geriatric Care Teams

With the growing population of frail elders, there is an
increase of geriatric patients requiring ongoing care for multiple medical
conditions. This creates the need for interdisciplinary geriatric care teams.
Often, the dynamics and culture of these teams differ across various sites of
care, such as assisted living, home care, hospitals, long-term care, and
rehabilitation facilities. As an advanced practice nurse, it is important to
understand your role in the care team as well as your potential impact on
patient care. In this Discussion, you explore models of interdisciplinary
geriatric care teams for different sites of care and the varying roles of the
advanced practice nurse.

Consider the following three case studies:

Case Study 1

Mrs. Martinez is an 83-year-old Mexican American widow who
lives in her own home and is cared for by her adult daughter. Mrs. Martinez
owns the home, and her daughter lives with her and provides the care. Her
daughter brought her mother to the clinic today to ask to speak to the social
worker. She requests that her mother be placed in a nursing home. The daughter
states that her mother has nothing to do during the day. The television is on
The Weather Channel most of the day because Mrs. Martinez has limited English
capability and is unable to read closed-captioning. Mrs. Martinez also has two
sons who do not live in the local area, but they do call regularly and check in
with their mother and sister. The two sons are opposed to moving their mother
to a nursing home because they had promised her that they would “never put her
away.”

Case Study 2

Mr. Williams, a 79-year-old African American widower,
resides in a foster care home. He has lived there for 4 years since his wife
died. He is a former minister. His medical history includes long-term diabetes,
high blood pressure, and benign prostatic hypertrophy. The home care provider
has requested a home visit to evaluate Mr. Williams’s ability to remain in the
home. The provider states that because Mr. Williams’s vision is seriously
compromised (he is nearly blind), and because he has been unable to get to the
toilet as quickly as necessary (he is very unsteady on his feet), his care is
becoming burdensome. According to the home care provider, for safety reasons,
Mr. Williams may not fit the criteria for remaining in the foster care home.

Case Study 3

Mrs. Randall is a 77-year-old female who resides in a
long-term care facility. She has a history of frequent falls and is severely
cognitively impaired. The nursing staff at the long-term care facility called
the nurse practitioner at the medical home office to report the recent
development of productive cough and high fever. There have been cases of flu in
the facility; however, Mrs. Randall has had a flu shot. The nurse practitioner
in the office requests a chest x-ray in the long-term care facility. The nurse
on duty in the facility states that there is no portable chest x-ray equipment
available. She further requests that Mrs. Randall be transferred to the
emergency room of the local hospital. Mrs. Randall’s daughter has durable power
of attorney for health care decisions for her mother. The long-term care
facility has notified the daughter of the change in her mother’s condition. The
daughter says whatever the nursing home wants is fine with her.

To prepare:

Review this week’s media presentation, as well as the
American Geriatrics Society and Arbaje et al. articles in the Learning
Resources.

Research models of interdisciplinary geriatric care teams
that are used at various sites, such as assisted living, home care, hospitals,
long-term care, and rehabilitation facilities.

Consider the model used for the interdisciplinary geriatric
care teams at your current practicum site. Compare this model to models used at
other sites.

Reflect on how the role of the advanced practice nurse
differs according to the site of care.

Select one of the three case studies. Consider how care
should be facilitated for the patient in the case you selected based on the
model used for the interdisciplinary geriatric care teams at your practicum
site.

Week 4 discussion

Discussion: Over-the-Counter Drugs

Pharmacokinetic and pharmacodynamic processes differ among
patients across their life spans. For geriatric patients, alterations due to
aging make them especially prone to adverse drug reactions. The various health
issues that affect many geriatric patients further complicate this, as the need
to treat these multiple health issues often results in polypharmacy. Although
treatments are frequently drugs prescribed by the health care provider, many
geriatric patients also take over-the-counter (OTC) drugs. While the provider
sometimes recommends these OTC drugs, patients often select the drugs on their
own. This makes patient education on pharmacology key when caring for geriatric
patients. Many patients assume that if drugs are available over the counter,
then they are safe to take. However, due to issues related to polypharmacy and
how their aging bodies process drugs, OTC drugs may have serious implications
for patients.

To prepare:

Review the American Geriatrics Society article and
interactive media piece in this week’s Learning Resources.

Select one of the following over-the-counter drugs commonly
used by geriatric patients:

Antacids or acid suppressants

Antidiarrheal

Antihistamines

Antimicrobial ointments

Antispasmodics for the bladder

Cough suppressants

Laxatives

Neutraceuticals (choose one; e.g., ginseng, St. John’s wart,
etc.)

Pain medications (choose one; e.g., acetaminophen,
ibuprofen, rub-on pain ointments/patches, etc.)

Supplements (choose one; e.g., calcium, iron, etc.)

Vaginal creams

Research the over-the-counter drug you selected. Visit a
local pharmacy and explore the types/varieties of the drug that are available.
Reflect on the ingredients in each type/variety, including additional active
ingredients.

Consult with the pharmacist about the ingredients in each
type/variety, including how to make safe and effective clinical decisions in
relation to this drug. Discuss potential interactions in frail elders and
precautions related to the drug based on Beers Criteria. If one is available,
you may consult with a pharmacist at your practicum site as an alternative to
visiting a pharmacy.

Consider ways to educate elders about the OTC drug you
selected.

Week 5 discussion

Discussion: Fall-Risk Assessment

Fall risks are very high for the geriatric population.
According to the Centers for Disease Control and Prevention (2013), one out of
every three adults aged 65 years and older falls each year. This can be
attributed to factors such as changes in aging, other health issues,
environment, and effects of prescribed drugs. When caring for geriatric
patients, it is important to screen them for risks and perform fall-risk
assessments. These assessment tools help to determine the level of risk for
patients so that preventive measures can be taken. The implications of falls
are very serious and range from fractures to mental health disorders and even
death. In this Discussion, you explore risk assessment tools for use with
patients at your practicum site.

To prepare:

Review the Kanis article in this week’s Learning Resources.

Consider a geriatric patient at your practicum site who is
at risk for falls. Coordinate an opportunity to assess this patient with your
Preceptor.

Note: When referring to your patient, make sure to use a
pseudonym or other false form of identification. This is to ensure the privacy
and protection of the patient.

In addition to the Fracture Risk Assessment Tool (FRAX),
select one of the following tools to assess this patient for falls:

Tinetti Performance Oriented Mobility Assessment (POMA)

Systems Approach

Berg Balance Scale

Elderly Mobility Scale

Timed Unsupported Stead Stand (TUSS)

Six-Minute Walk Test (6MWT)

Hendrich II Fall Risk Model

Consider why you selected the assessment tool for this
particular patient.

Assess the patient using the tool you selected under
Preceptor guidance. Reflect on the assessment, including any issues with the
patient and/or the effectiveness of the tool.

Think about strategies and interventions to reduce the risk
of falls for frail elders.

Week 6 discussion

Discussion: Patient Presentation of Dementia, Delirium, and
Depression

With the prevalence of dementia, delirium, and depression in
the growing geriatric population, you will likely care for elderly patients
with these disorders. While many symptoms of dementia, delirium, and depression
are similar, it is important that you are able to identify those that are
different and properly diagnose patients. A diagnosis of one of these disorders
is often difficult for patients and their families. In your role as the
advanced practice nurse, you must help patients and their families manage the
disorder by facilitating necessary treatments, assessments, and follow-up care.
Consider the patient presentations in the following case studies. What distinct
symptoms or factors would lead you to a diagnosis of dementia, delirium, or
depression?

Case Study 1

HPI: Mrs. Mayfield is a 75-year-old woman who is brought to
the emergency room by the police at 11 p.m. She was found wandering and
confused in a local neighborhood. The police were called when Mrs. Mayfield
tried to use her key on a neighbor’s door. When confronted by the police she
became abusive, confused, and frightened and looked very pale and agitated. The
police could not establish her correct address and they subsequently brought
her to the emergency room.

Review of Symptoms (ROS): Unable to obtain at this time.

Objective Data:

PE:

VS: Pulse 96 and regular; B/P 150/90; Axillary temperature
99°F.

General: She appears clean and well nourished, with no signs
of injury, trauma, or neglect.

Her physical exam is unremarkable except –

Neuro: No gross focal neurological signs, but she is only intermittently
cooperative. Her mental status fluctuates and a full neurological evaluation is
not possible at this time.

Psych: A & O x 1 to person only. She has episodes of
agitation and alternating withdrawal/somnolence. During the examination, it
takes several attempts to gain Mrs. Mayfield’s attention to answer questions,
but once focused, she rambles on in a disorganized and incoherent way.

Case Study 2

CC: “irritable and forgetful”

HPI: Mrs. White, a 78-year-old married woman, is brought to
the office of her primary care provider by her husband because of increasing
forgetfulness and irritability over the past 3 months. Mr. White claims that
his wife has had problems for several years now, but has just gotten “worse in
her memory” in the past few months. She recently misplaced her purse and
accused her son of stealing it.

On three occasions, she left the stove on and boiled a pot
dry, nearly causing a fire. She recently put a container of ice cream into the
washing machine instead of into the freezer and her husband did not discover it
for more than a week. Mrs. White claims her family wants to take her money and
leave her with nothing. “No matter what they say, there is nothing wrong with
me,” she states.

Past Medical History (PMH) includes: hypothyroidism, treated
with Synthroid, and successful treatment of breast cancer approximately 15
years prior. She also takes over-the-counter ibuprofen for chronic lower back
pain and occasional Benadryl to help her sleep at night.

Objective data: Her physical examination is within normal
limits.

Case Study 3

HPI: Mr. George is a 72-year-old male who has lived alone
since his wife died approximately 1 year ago. He has lived in the same house
for 45 years. He is brought in by his son who is concerned that his father has
lost more than 35 pounds over the past year. Mr. George admits to not eating
well because “I don’t know how to cook for myself.”

PMH: He has been in good health with the exception of
hypertension, which is well controlled.

Social history: He spends most of his time watching sports
on television. He occasionally drinks one or two cans of beer when he is
watching TV. He does go to his son’s house to visit with his grandchildren
about once a week, and he says he enjoys that. He does not receive any social
services, he still drives but only in the daytime, and he does not participate
in any other leisure activities.

Objective data: His physical examination is normal. He
responds correctly to questions, although he appears to have a flat affect.

To prepare:

Review Chapters 6–8 of the Holroyd-Leduc and Reddy text.

Select one of the three case studies. Reflect on the way the
patient presented in the case study you selected, including whether the patient
might be presenting with dementia, delirium, or depression.

Think about how you would further evaluate the patient based
on medical history, current drug treatments, and the patient’s presentation.
Consider whether you would modify drug treatments, use additional assessment
tools, and/or refer the patient to a specialist.

Week 7 discussion

Discussion: Nutrition and Hydration

Geriatric patients have many nutritional and hydration
concerns that impact their health and ability to acquire sufficient nutrients.
Advanced practice nurses evaluating these patients must be able to account for
all barriers that prevent elders from obtaining adequate nutrition, including
medical conditions, transportation, finances, physiologic changes, and
functional abilities. When evaluating patients, it is important to consider how
they eat, what their diet consists of, and whether they have any special dietary
needs that are not being met. Assessment tools, such as the Lawton Instrumental
Activities of Daily Living (IADL) Scale, are an integral part of this
evaluation process as they help providers identify potential obstacles for
patients. In this Discussion, you assess a patient at your current practicum
site and consider strategies for improving any nutrition or hydration issues.

To prepare:

Review this week’s media presentation, as well as 29 and 30
of the Resnick text.

Assess a patient using tools for inpatient and long-term
patient care, such as the Lawton IADL Scale.

Note: You should coordinate this opportunity with the
Preceptor at your practicum site.

Consider whether nutrition and/or hydration might be
impacted by the patient’s functional abilities. Reflect on whether the patient
is able to go out and get food to eat, cook meals, safely use the stove, etc.

Consider the patient’s diet and whether they have any
special dietary needs due to medical conditions, such as congestive heart
failure, end-stage kidney disease, diabetes, oral health issues, etc. Reflect
on whether or not the patient is attempting to compensate for a medical issue
and thus creating a deficiency or excess in his or her diet.

Based on your patient assessment, think about strategies for
improving any nutrition issues that might have presented (e.g., nutritional
supplements, community resources such as Meals on Wheels, referral to a
nutritionist or dietician, etc.).

Week 8 discussion

Discussion: Nursing Homes in Your Community and Neighboring
Communities

Nursing homes have become a viable option for geriatric
patients who require routine care and need help performing basic activities of
daily living, with about 3.3 million patients residing in nursing homes in the
United States (Centers for Medicare & Medicaid Services, 2013). While
nursing homes provide care and services to patients, problems can arise
resulting in reduced quality of care and, in some cases, illness and morbidity.
The severe implications of pressure ulcers make them a major concern for elders
residing in nursing homes. The Centers for Medicare & Medicaid Services
(2013) estimate that 7.5% of nursing home residents have pressure ulcers and
about 82,000 patients develop them each year. In your role as the advanced
practice nurse, you must understand factors that contribute to the incidence of
pressure ulcers in order to improve patient outcomes.

For this Discussion, you examine the prevalence of pressure
ulcers in nursing homes and develop strategies for increasing awareness and
reducing incidence.

To prepare:

Review Chapter 32 of the Resnick text and Chapter 12 of the
Holroyd-Leduc and Reddy text.

Select four nursing homes in your community and/or
neighboring communities. Research and locate reports on these nursing homes
through organizations such as Centers for Medicare & Medicaid Services.

Compare the four nursing homes you selected based on
reported cases of the development of new pressure ulcers.

Think about factors in the nursing home setting that
contribute to pressure ulcer issues, such as patient activity, nutrition, or
the number of staff available to care for patients.

Research guidelines for the prevention of pressure ulcers.
Think about how you might increase awareness among nursing home staff about the
incidence and consequences of pressure ulcers in patients.

Week 9 discussion

Discussion: Treating Patients in Specialized Areas of Care

When treating frail elder patients in specialized areas of
care, there are various dynamics that might impact patient care plans. From
questions about potential outcomes, benefits of treatment, and quality of life
to factors such as personal values, families, culture, and religion, decision
making can be difficult for patients and their families. As the advanced
practice nurse, you must support them through this process.

For this Discussion, you examine the following case studies
and consider how you might address the needs of the patients and their
families.

Case Study 1

Mr. Wiggins is a 78-year-old African American male with
chronic kidney disease, which requires dialysis. The etiology of his renal
disease was multifactorial—long-standing uncontrolled HTN and DM nephropathy.
He has been on hemodialysis for the past 10 years and has done relatively well.
Four weeks ago, he had a major CVA and is minimally responsive. His condition
is not expected to change, and the family is having a difficult time with his
recent health changes. Advanced directives were discussed with them, and his
wife is a durable power of attorney for his health care. The wife hates to see
her husband this way and understands this is not how he would want to go on,
but their children and many of the family members (his brothers and sisters)
think the patient will return to himself. They want everything done in terms of
life support measures—full code status. His family wanted a feeding tube
placed, and he is now receiving 24-hour tube feedings. You are the NP caring
for Mr. Wiggins. You have known and cared for him and his wife for several
years. The wife pulls you aside, shares her dilemma, and asks you to make the
decision regarding continuing medical care/support for her husband. How will
you respond?

Case Study 2

Mrs. Adams is a 96-year-old Caucasian female who has
recently been diagnosed with colon cancer. She was admitted to the hospitalist
service through the ED with dehydration and rectal bleeding. The bleeding
resolved, and she received 2 units of PRBs and fluid/electrolyte replacement.
She is stable and ready to be discharged home.

Mrs. Adams is in remarkably good health, and other than
arthritis and mild HTN, she has no significant medical or surgical history. She
is able to carry out all of her essential daily living activities. She pays her
own bills, is competent, and has good functional abilities. She was driving up
until last year. Now, she has neighbor’s assist with weekly shopping and
transportation to church. Her sensory, functional, and cogitative abilities
were evaluated this admission and remain intact. She has been offered
palliative surgical intervention, but deferred all treatment. Her only son is
in agreement with his mother’s decision. Her parents and husband are deceased.
You have been asked to obtain advanced directives. What will your discharge
treatment plan be for Mrs. Adams?

Case Study 3

Mr. Pierce is an 82-year-old East Indian male, recently
widowed 6 months ago. He fractured his left hip 2 months ago attempting to
climb his backyard fence to get his cat out of a tree. His children live
internationally and have been taking turns caring for him. His eldest son
brought him in through the ED last night because Mr. Pierce started having
shortness of breath and his lips turned blue. In addition, his son noticed his
left leg was very swollen compared to the right. The ED nurse practitioner
ordered a thin cut cat scan (CT) with pulmonary embolism (PE) protocol and deep
vein thrombosis (DVT) scan. Mr. Pierce has a large DVT that is obstructing
circulation and multiple pulmonary emboli. His condition is life threatening
and he is only expected to live a few weeks. He has a living will and advanced
directives and has requested to be able to die in the comfort of his home. “I
hate hospitals.” You have been consulted at the patient and family’s request
because you are Mr. Pierce’s primary care provider. What additional services
can be offered to ensure his care/comfort at home and to give him peace of mind
regarding his estate?

To prepare:

Select one of the three case studies. Reflect on the
provided patient information.

Think about potential outcomes for the patient in the case
study you selected.

Consider how care, treatment, and/or support might be
facilitated for the patient. Reflect on how you might also address the needs of
the family.

Week 10 discussion

Discussion: Community Advocacy Agencies

Having received a diagnosis of Alzheimer’s and encountering
the associated stigmas, Michael Ellenbogen encourages increased advocacy
efforts for the geriatric population struggling with this disease. He says, “We
did nothing wrong to get this disease, and we need to speak up to let our voice
be heard…There are no excuses for not wanting to help. The human cost factor is
too high, and we are all accountable to do something” (Ellenbogen, 2012). As an
advanced practice nurse caring for the geriatric population, it is important for
you to join in advocacy efforts within your community whether it is in support
of Alzheimer’s or another prevalent need such as abuse. You should be aware of
community agencies that advocate for the well-being and care of your local
geriatric population, as these agencies often provide resources and assistance
to the elderly in need. In your role of care, you are able to identify
prevalent needs and work with patients, their families, and agencies to promote
change and impact lives.

To prepare:

Review this week’s media presentation, as well as the
American Geriatric Society’s Public Policy and Advocacy website in the Learning
Resources.

Locate and research two agencies that advocate for the
elderly in your community. Consider their current advocacy actions and/or
campaigns.

Reflect on your experiences and observations at your
practicum site. Consider new advocacy actions you might suggest to the agencies
you selected. Based on these advocacy actions, think about new policies that
might improve the care of the population at your current practicum site.

Week 11 discussion

Discussion: Discussing End-of-Life Care

There is a human tendency to postpone uncomfortable or
unpleasant tasks.

—Nancy Kummer, geriatric patient

This human tendency to avoid the unpleasant makes
end-of-life care and hospice decisions difficult for many patients to discuss
with their families. Kummer is a former social worker who used to counsel
patients with terminal illnesses, yet she avoided discussing her own
end-of-life wishes with her children. While many Americans, like Kummer, agree
that these discussions need to take place, few have actually had these
conversations with their families (Lazar, 2012). Although initiating
conversations about end-of-life care and hospice might be difficult for
patients, as an advanced practice nurse, facilitating these conversations is an
integral part of your geriatric nursing practice. For this Discussion, consider
how you would facilitate care conversations with the patients and families in
the following case studies:

Case Study 1

Mrs. Sloan, a 69-year-old widow, is about to enter the
hospital for an elective cholecystectomy; she is being medically cleared by her
primary care provider. During the discussion, she requests to be placed on a no
code status during her hospitalization. Mrs. Sloan claims that besides her
gallbladder problem, her general health status is good. She wishes to have the
surgery to avoid any further attacks, which have been very painful. She states,
however, that if during surgery or her postoperative period, she undergoes a
cardiac arrest, she would prefer not to be resuscitated. She has read about the
chances of successful resuscitation, and has determined that the risk of brain
damage is too high. For this reason, she is requesting a no code status.

Case Study 2

Ms. Stearns is an 83-year-old nursing home resident with
hypertension, coronary artery disease, arthritis, renal insufficiency, hearing
impairment, and a previous history of stroke. She also has a foot deformity
from childhood polio. She is disoriented at times. She has lived in the nursing
home for 10 years and rarely leaves the chair beside her bed. She has recently
developed urinary incontinence, but has refused a bl

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