Resident Choice Made Easier

A new tool enables better care planning, delivery, and quality management for older adults.

 FEBRUARY 2013

 Kimberly Van Haitsma, PhD

Now that person-centered care is becoming the new standard in post-acute and long term care settings, providers are increasingly shifting away from the traditional medical model toward a new focus on improving consumers’ quality of life. However, making this cultural shift—to meet individualized psychosocial and physical needs—can be challenging. Providers need practical, efficient tools to translate the vision of person-centered care into on-the-ground reality.

 

A team of researchers and clinicians at a senior care provider in Philadelphia developed a new assessment tool that captures the psychosocial preferences of older adults and speeds the adoption of more person-centered care practices.

 

Known as the Preferences for Everyday Living Inventory (PELI), this useful rubric yields vital data about older adults’ individual preferences for social contact, personal development, leisure, living environment, and daily routine.

 

It can also be used to assess health care access and family involvement in care and to help providers refine and customize care plans and service delivery.

 

Nursing homes may find PELI helpful as they shift from an institutional model of clinical efficiency toward a culture of greater responsiveness to residents’ wishes, interests, and desire for a sense of purpose and control.

 

It provides a useful level of specificity that can be deployed to guide staff training; measure quality improvement; and align services more closely with expectations of consumers, families, and regulatory agencies.

How PELI Works

PELI consists of 55 questions in five domains of daily life: social relationships, growth and diversionary activities, self-dominion, and enlisting others in care. Fourteen of the questions are consistent with the minimum data set (MDS) 3.0 for nursing homes but delve more deeply into residents’ preferences for everyday living.

 

Phrased in clear, conversational language, the questions elicit basic and in-depth insights about daily preferences, such as what time individuals like to wake up, take a shower, and get dressed, and what kinds of recreational activities they enjoy.

 

Professional and paraprofessional staff can administer PELI in one sitting, or over a series of conversations. Optimally, the questions are asked annually or at more frequent intervals, as well as when a person begins receiving service and experiences a significant change in status.

 

PELI is the first tool of its kind to pass rigorous scientific testing. In 2005, it was piloted with more than 500 home health clients enrolled in the Visiting Nurse Service of New York. The tool proved to be a reliable and valid measure of preferences and was well accepted by a wide range of older adults.

 

An advisory panel of long term care experts concurred that it covered the key aspects of daily life. While PELI has been tested in home health and nursing home settings, it is also designed for use in subacute, rehabilitation, and assisted living facilities. 

Residents’ Perspective On Sharing Preferences

In the pilot study, as well as at a 324-bed nursing facility, staff found that residents enjoy reflecting on what is important in their lives and appreciate the opportunity to voice their preferences to an interested listener. These kinds of focused, thorough discussions aren’t the norm in service settings. Yet they are deeply meaningful to consumers and form the foundation for comfortable, trusting relationships with staff.

 

Emerging research indicates that integrating preferences into care delivery for older adults is beneficial. When activities are appealing, or services are provided in a familiar way, seniors are more apt to be receptive, enjoy the experience, and feel validated. These positive feelings have a measurable effect on physical and mental well-being among people of all ages.

 

Data and insights elicited by PELI ensure that the consumer’s voice is heard and help the whole team—client, family, and staff—work together toward the same goals. At the nursing home, matching preferences to activities tripled resident participation in recreational activities.

 

PELI has also been used to assess broad-ranging outcomes. So far, its use has resulted in greater congruence between preferences and activities, leading to fewer behavior issues among residents, as well as reduced levels of depression and fewer falls.

 

Data are being compiled for a more comprehensive study of this dynamic.

Advantages For Providers

Direct care staff members use PELI to get to know consumers, build relationships, and devise more successful care plans. The questionnaire provides a consistent protocol to discover each client’s unique interests, passions, and priorities.

 

“PELI is a great tool for becoming better acquainted with new residents,” says Sarah Humes, a recreation therapy supervisor.

 

“It’s especially helpful for paraprofessional staff who may not have clinical training because it provides a way for them to learn more about the residents in their care and organize the information.”

 

The nursing home team divides up responsibility for different sections of the PELI questionnaire. Recreation therapists talk to residents about their activity preferences, and certified nurse assistants handle questions about activities of daily living. Staff implement what they learn immediately and share findings at team meetings where they collaborate to customize care plans.

A Positive Response

Humes says the process also improves job satisfaction. Findings inspire staff to stretch professionally to find ways to honor customer preferences. The tool asks seniors to talk about activities that they enjoy even if they feel that they can no longer do them. When the team understands what interests and motivates residents, they are eager to work collaboratively to prevent them from giving up treasured skills and activities prematurely.

 

PELI findings have also been used to assess individual practice, such as “Am I meeting Mrs. Jones’ preferences this week?” at the unit level. Recreational therapists now aggregate residents’ preferences on each 27-person unit household to plan program offerings that meet the group’s top shared priorities.

The resulting household activity board reflects residents’ authentic interests.

 

The nationally recognized Green House Project now uses PELI in its train-the-trainers curriculum for Green House adopters nationwide. Those selected to be educators, including nurses, social workers, and activity directors, practice using PELI with an older adult and create an engagement activity based on interview findings.

 

The exercise gives educators firsthand experience with deep listening and linking preference assessment to care.

 

“PELI provides specificity for a paradigm shift that’s key to forming deep, knowing relationships with elders,” says Susan Frazier, Green House Project chief operating officer. “It helps sensitize direct care staff so they can offer life-enriching experiences that are significant to each elder. For example, residents love being asked not just if they like to read, but what they like to read and how important reading is to them.”

 

A Philadelphia nursing home began using PELI this year to measure delivery of person-

centered care. Without a structured system to gauge resident preferences, activity programming reflects the recreational therapist’s best guess as to what a resident wants. Recreational options may be biased or limited by the therapists’ own interests.

 

PELI’s impact is being measured by examining progress on one or more areas of person-centered care in both PELI and the MDS 3.0. Although quantitative data aren’t yet available, anecdotal feedback indicates that preference-based care yields better satisfaction for families, staff members, and especially residents.

When a trusted, understanding caregiver presents activities or services in a palatable way, a resident is less likely to become frustrated, confused, or agitated and more likely to become meaningfully engaged.

Studies show that staying active and connected socially are closely linked with preventing or mitigating symptoms of depression in nursing home residents.

Looking To The Future

The Abramson Center research team continues to refine the PELI tool by testing it with diverse populations of older adults. They are also conducting studies on the impact of preference-based care on nursing home residents’ quality of life, as indicated by the presence of depression or behavioral symptoms.

 

The Advancing Excellence in America’s Nursing Homes campaign recently has announced new goals that focus in part on person-centered care.

 

According to Mary Jane Koren, MD, immediate past chair of the campaign, the initiative will include PELI as one of the resources offered to nursing homes as part of its evidence-based toolkit of interventions and educational materials. “It’s an intuitively straightforward tool that’s useful not just for the long-stay population but for the short-stay population as well, because it allows you to frame rehabilitation programs around patient preferences,” says Koren.

 

UTAH CNA SCHOOLS

UTAH CNA TRAINING

UTAH CNA CLASSES

SALT LAKE CNA TRAINING

SALT LAKE CNA SCHOOL

TWO WEEK SALT LAKE CNA CLASS

UTAH CNA SCHOOLS

UTAH CNA TRAINING

UTAH CNA CLASSES

SALT LAKE CNA TRAINING

SALT LAKE CNA SCHOOL

TWO WEEK SALT LAKE CNA CLASS

UTAH CNA SCHOOLS

UTAH CNA TRAINING

UTAH CNA CLASSES

SALT LAKE CNA TRAINING

SALT LAKE CNA SCHOOL

TWO WEEK SALT LAKE CNA CLASS

CNA CLASSES

Nurses in drive for 'compassionate care'

COMMENTS (648)

More emphasis should be placed on nurses providing compassionate care in hospitals, industry leaders have said.

In a new campaign aimed at reassuring the public, chief nursing officer for England Jane Cummings said action must be taken to ensure the values nurses stand for are not betrayed.

The call comes amid concern over reported neglect and abuse in hospitals and care homes.

The Patients Association said the plans must be translated into action.

Following an eight-week consultation involving more than 9,000 nurses, midwives, care staff and patients, Ms Cummings will tell a conference in Manchester how she plans to embed values such as compassion, communication, and commitment in public health care.

'Poor care a betrayal'

It is more than three years since the scandal triggered by unusually high death rates at Stafford hospital provoked deep unease over the culture of care in the health service.

Since then a succession of inquiries and reports into the NHS and other care settings has reinforced these concerns, which have become an urgent political priority.

With the launch of Compassion in Practice - a three year strategy for nursing - Ms Cummings will call for new ways of measuring patient feedback, getting trusts to review their culture of care and their staffing levels and explaining in public how they impact on standards.

Ms Cummings is expected to say: "The context for health care and support is changing. Most significantly, with people living longer, we have a greater number of older patients and people to support, many with multiple and complex needs.

"And while the health, care and support system provides a good - often excellent - service, this is not universal. There is poor care, sometimes very poor. Such poor care is a betrayal of what we all stand for."

'Difficult to implement'

Speaking to BBC Radio 4's Today programme, Peter Crome, emeritus professor of geriatric medicine at Keele University, explained what the drive was aiming at.

He said: "I believe what they mean is that nurses and other care staff - whether they're in hospitals, hospices or in the community - should take a more caring and compassionate role when it comes to looking after vulnerable groups, rather than what is often seen as a very task-oriented approach."

Prof Crome said it was possible to focus on technical aspects of nursing at the same time as basic care, adding it was crucial to have care values "reinforced in the the training environment and the working environment".

In particular, he said it was important to observe, monitor, instruct and if necessary correct those training in care.

"But without adequate numbers of trained staff, this agenda - which must be welcomed - will be difficult to implement," he said.

UTAH TWO WEEK CNA CLASS

Having fun at virtual day. CNA CLASS UTAH

Let's give this woman a bed bath.  CNA CLASS UTAH

Hoyer lift to the rescue.
UTAH CNA CLASS

Posing with the Hoyer.
UTAH CNA CLASS
UTAH CNA SCHOOL
UTAH CNA TRAINING

Have wheelchair, waiting for patient.
UTAH CNA SCHOOLS
SALT LAKE CNA CLASS
SALT LAKE CNA TRAINING

Why'd you call 911

http://www.youtube.com/watch?v=bekWx73JSvk&feature=youtu.be

TELEMEDICINE

Telemedicine Facilitates
‘House Calls’

By Jessica Girdwain
Aging Well
Vol. 5 No. 6 P. 10
For older adults who don’t have the means to visit a doctor, the University of Rochester Medical Center (URMC) in New York may have a novel solution: telemedicine. It’s conducting a research project with 250 participating elders, evaluating the effectiveness of using technology that’s similar to Skype or videoconferencing to conduct medical evaluations—and it’s paying off.
“This technology is patient centered and completely revolutionary,” says Manish N. Shah, MD, MPH, an associate professor of emergency medicine, community and preventive medicine, and geriatrics/aging at URMC.
The technology is especially important in the geriatrics field. The shortage of geriatricians and the large number of aging baby boomers who will need care in the coming years will put a strain on doctors. Technology that streamlines the appointment process allows more patients to be cared for in a shorter period of time.
URMC is certainly in the top tier in telemedicine practice. The technology has been around for decades. In the 1960s, it was done via telephone lines in some cases. The technology wasn’t efficient and was very expensive. But the program has developed it into a viable tool that mimics a traditional office visit but is conducted from 20 or 30 miles away.
“It’s tough to go to an office if you’re an older adult. Maybe you have to arrange transportation to go to the doctor, or maybe you have functional limitations or can’t navigate a massive medical center. With this technology, elders don’t have to worry about those things,” Shah says.
Coordinating Personnel and Equipment
So how does it work? A telemedicine technician (typically a nurse practitioner, physician’s assistant, or EMT) travels to the patient’s home or elder care facility with equipment that will facilitate conducting a typical office visit. Equipment used may include an electronic stethoscope, high-definition video camera, and an otoscope, among other instruments. They all connect to the computer via USB ports. The technician asks the patient basic health questions, takes vital signs, and photographs the patient’s medical complaint, if necessary. Healthcare workers can provide access to other indicators too. For example, they can record lung sounds and upload data onto software for the physician to evaluate. They are also trained in drawing blood and taking X-rays.
The doctor then logs on to the computer from his or her office or hospital and reads through the patient’s history, looks at the photos, and considers any other pertinent information that may contribute to arriving at a diagnosis. If a prescription is needed, computer software allows the physician to send one to the appropriate pharmacy.
“The technology is so simple,” Shah says. “You can essentially do all of the things you normally do during an office visit, but this is via the Internet.”
The time required for the doctor to “see” the patient is five to 10 minutes. Because appointments don’t need to be live, physicians can review the information at a later time. The technician may spend 30 to 60 minutes per case, depending on the care needed.
“This is certainly more efficient for the physician because it gives the doctor all of the information that’s needed in a nice neat package,” Shah says. Most importantly, it benefits elderly patients by making them more receptive to care when they don’t have to leave their homes.
Expanding Medical Coverage
“For many elders, [they] would not get any care at all if it weren’t for telemedicine,” says Terry Rabinowitz, MD, DDS, director of psychiatric consultation and telemedicine services at the University of Vermont College of Medicine and Fletcher Allen Health Care in Burlington, Vermont. He provides necessary psychiatric care for patients in two nursing homes via telemedicine in both Burlington and upstate New York.
“Over 25% of the elderly population have psychiatric conditions that need to be addressed, like depression, dementia, and delirium. Without telemedicine, they may not get the help they need. Many of these patients live in rural areas, and a doctor is not able to drive hours to see them,” he says. For example, for Rabinowitz to see patients in upstate New York, he’d have to travel two hours one way for a one-hour consultation. Of course, allotting five hours per patient isn’t sustainable for any practice.
Another benefit Rabinowitz finds is that older patients simply enjoy the technology and are happy and touched that a doctor takes special pains to see them. “What it comes down to is that telemedicine is exactly like being there face to face. If the practitioner behaves as if the patient is in the room with them, the patient will behave that way too. It takes very little time to adapt to the videoconferencing approach. In fact, if I had to, I could conduct a consultation on my iPhone,” he says, although most of his consultations are done through traditional telemedicine methods.
Successful Strategy
Physicians interested in bringing this type of telemedicine to their practices should be aware of a few points, according to Shah. First, the ideal situation for telemedicine is based on a strong geriatrics practice. URMC’s program has enrolled 250 patients in their telemedicine project, resulting in about 10 visits per week, which provides insufficient volume to keep full-time technicians and practitioners employed. The model best caters to geriatricians who are partners in a practice because they can take care of patients in an assisted-living facility together.
Also, health practitioners should be aware that telemedicine equipment can range from inexpensive—for example, a $30 webcam—to as much as $30,000 for state-of-the-art high-definition equipment. The more expensive versions would transmit with a quality and resolution equivalent to watching a high-definition television show. But the cost largely depends on what functionality is required. For Rabinowtiz, the equipment he uses falls around $4,000 because with psychiatry, he needs a good-quality camera and video monitor. “I need to see facial expressions, but I might not need to see every wrinkle in the skin,” he says.
Start-up costs include buying equipment and paying a technician’s salary. It’s worth checking with insurance providers on potential coverage of related costs, according to Shah. It’s also important to build in time for technicians to train on the equipment. URMC provides a training program that teaches technicians to use new equipment and pairs them with a geriatrician to learn how to communicate with older adults. The full training process takes about one month.
— Jessica Girdwain is a Chicago-based freelance writer who has contributed health-related articles to several national magazines.

DEMENTIA RELATED BEAHVIOR MANAGEMENT

Dementia-Related
Behavior Management

By Mark D. Coggins, PharmD, CGP, FASCP
Aging Well
Vol. 5 No. 1 P. 32
Dementia describes a group of symptoms resulting in a gradual and progressive decline in memory, thinking, and reasoning abilities. While most dementias are progressive with no cure, approximately 20% are reversible. Healthcare professionals should closely evaluate patients with cognitive decline for possible underlying treatable conditions.
Medication-induced dementia is the most common cause of reversible dementia. Elders are especially vulnerable due to concomitant illnesses, reduced renal and liver function, and the simultaneous use of multiple medications.1
Other common reversible causes include depression, infection, high fever, vitamin deficiencies, poor nutrition, hypercalcemia, brain tumors, thyroid disorders, and hypoxia due to lung and heart diseases.
Alzheimer’s disease (AD) is the most common type of irreversible dementia. Other irreversible types include vascular or multi-infarct dementia, dementia with Lewy bodies (DLB), frontotemporal dementias (Pick’s disease), and Parkinson’s dementia (PD). Autopsy studies have shown that most dementia patients had brain abnormalities consistent with more than one dementia type.
Dementia Behaviors
In addition to progressive cognitive loss, almost all AD patients develop personality and significant behavioral changes. Mood disorders such as depression; nonpsychotic behaviors such as restlessness, wandering, and aggression; or psychotic symptoms, including hallucinations and delusions, often occur with severe disruptive behaviors, leading to 50% of nursing home admissions, according to the American Academy of Family Physicians.
Healthcare professionals should consider behaviors as a means of patient communication as AD patients lose their ability to adequately make their needs known. Agitation may be a result of underlying precipitating causes such as hunger, thirst, pain, or infection. Be aware that medication changes or poor hearing can increase confusion. Vision issues can contribute to visual hallucinations or increase a patient’s feeling of vulnerability or fear.
The failure to identify causes of these behaviors may leave a patient in distress and often results in the unnecessary use of behavior management medications. These may do little more than cause sedation and can lead to further cognitive decline, reduced patient activity, worsening incontinence, and falls, and make it more difficult for caregivers to provide assistance.
In cases where the behavior or psychiatric symptoms are severe, distressing, or may lead to harm, it may be necessary to prescribe medications.
Antipsychotic Use and Associated Risks
Antipsychotic use in dementia patients continues to be widespread despite clear and substantial risks to patient health.
All antipsychotic medications include FDA black box warnings due to the increased risk of death when used in dementia-related psychosis. Additional concerns include negative metabolic effects, weight gain, type 2 diabetes, dyslipidemia, and increased risk of stroke. Antipsychotics are also linked to a worsening decline in cognition consistent with one year’s deterioration compared with placebo.
Antipsychotics in AD patients should be reserved for behaviors that are harmful or when distressing psychotic features exist. They should be given short-term and at the lowest possible dose with frequent evaluation for discontinuation, according to the 2001 report “Psychotropic Drug Use in Nursing Homes” by the Office of Inspector General.
The widespread use of atypical antipsychotics despite the risks highlights the need for alternative behavior management medications and strategies.
Medication management in dementia patients can be complex. Unfortunately, no silver bullet exists for prescribers to call on to address dementia-related behaviors. Successful behavior management most often involves a combination of nonpharmacological approaches tailored to meet a patient’s needs in addition to one or more of the currently available medications, which often have limited supporting evidence in their effectiveness on behaviors.
Pain Treatment Can Influence Behaviors
Pain can diminish cognitive function, reduce patients’ ability to perform activities of daily living, adversely affect mood, and reduce quality of life.
In a 2010 study conducted at a Golden LivingCenter in Hendersonville, North Carolina,2 researchers found that increased pain management focus in nursing home patients with dementia helped reduce episodic behaviors. A certified geriatric pharmacist (CGP) provided education on pain assessment and treatment options to all nursing home staff and direct care assistants.
The CGP evaluated medical records of patients with such behaviors to determine whether common conditions known to cause pain, such as osteoarthritis, wounds, and neuropathy, were being treated. Recommendations based on the American Medical Directors Association pain management guidelines, including acetaminophen and other medications, were discussed with each patient’s physician, and appropriate medication changes were implemented. Following the treatment modification, the patients’ behaviors were tracked and were noted as significantly reduced, and nurses and nursing assistants noted that patients had become less resistant to care.
Additional follow-up discussions occurred between the nursing home interdisciplinary team and the CGP. As patient behaviors improved, the interdisciplinary team worked with prescribers to significantly reduce the number of antipsychotic, anxiolytic medications (benzodiazepines) and sedative/hypnotics being taken by these patients.2
Nursing home patients in Norway and England with moderate to severe dementia experiencing agitated behaviors had acetaminophen added to their existing pain orders or, if acetaminophen was already ordered, low doses of morphine, or they were given antiepileptic medications for neuropathic pain. Patients receiving more aggressive pain management had a significant reduction in undesirable behaviors. Following eight weeks of therapy, pain treatment added to the intervention group was gradually reduced. Follow-up four weeks later showed the recurrence of the behavior symptoms and further demonstrated the effectiveness of pain management in reducing negative behaviors.3
Cognitive Enhancers
Medications commonly given to slow the progression of cognitive loss in dementia have shown modest benefit in controlling behaviors.
In several studies, acetylcholinesterase inhibitors (AchEIs), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyme) demonstrated some success in reducing dementia behavioral symptoms, including apathy, anxiety, delusions, and hallucinations. These medications appear to be effective in treating psychotic symptoms in patients with DLBT and PD.
Memantine (Namenda), an NMDA receptor antagonist used alone and with AchEIs, has shown moderate improvements in behavioral symptoms, including agitation, aggression, irritability, lability, and delusions. Additional benefits have been seen when using memantine together with AchEIs.4
Antidepressants
Researchers have reviewed the evidence for the effectiveness and safety of antidepressants for dementia-related agitation and psychosis. While larger well-controlled studies are needed, many existing studies have provided hope that antidepressants, especially those known as selective serotonin reuptake inhibitors (SSRIs), have safe and tolerable side effect profiles and can be effectively used to help dementia-related behaviors in some patients.
Most of the studies involved SSRIs such as citalopram (Celexa) or sertraline (Zoloft). Improvements in depression, emotionality, anxiety, agitation, and social interaction have been seen when comparing citalopram with placebo.
In a study at the University of Pittsburgh Medical Center conducted with patients hospitalized with psychiatric disturbances related to dementia, patients receiving citalopram experienced similar results, or a 32% reduction in relieving hallucinations, delusions, and suspicious thoughts while those in the atypical antipsychotic risperidone (Risperadal) group had a 35% reduction. However, the patients receiving citalopram experienced a 4% reduction in side effects compared with a 19% increase in side effects in patients receiving risperidone.5
Many antidepressants have been shown to have favorable effects on anxiety, sleep disturbance, and agitated behaviors. Practical suggestions on ways to implement the use of antidepressants for behaviors may include selecting an agent based on the known beneficial effects and the specific behavioral symptoms exhibited.
SSRIs such as escitalopram (Lexapro) and sertraline have indications to treat anxiety. Because anxiety and agitation are often closely related, a reasonable selection of one of these antidepressants may be made for those dementia patients exhibiting signs and symptoms of depression with anxious agitated behaviors.
Prescribers may choose to start antidepressant medications such as SSRIs while slowly reducing or eliminating the use of higher risk medications, such as antipsychotics and benzodiazepines that are often used for anxiety. This can have further benefits for the patient since these medications are known to increase confusion and fall risk.

Depression is known to affect sleep in many patients with and without dementia. Patients receive benzodiazepines or hypnotic medications such as zolpidem (Ambien) for sleep, which has been linked to early morning falls. Physicians may choose to utilize the antidepressant mirtazepine (Remeron) at a dose of 30 mg for which there are studies showing improved sleep continuity long term.
Patients with dementia and diabetic neuropathy who exhibit undesirable behaviors may be experiencing pain. Consideration for this type of patient may be given to duloxetine (Cymbalta), an antidepressant known to help neuropathic pain and depression.
Pharmacological choices with FDA-approved indications and clear evidence in targeting behaviors in dementia are limited. However, improved nonpharmacological interventions, in addition to focused patient individualized prescribing targeting common underlying causes of behaviors seen in dementia patients, may allow for improved behavior symptom control with less risk than is currently seen today utilizing atypical antipsychotic medications.
— Mark D. Coggins, PharmD, CGP, FASCP, is the national director of clinical pharmacy services for more than 300 skilled nursing homes operated by Golden Living. He was recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.

References
1. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9);1107-1116.
2. Coggins M, Evans MP, Bruce C. Effect of an interdisciplinary team approach to psychotropic drug reduction and elimination on quality measures and other clinical outcomes in skilled nursing facilities (SNFs): the Medication Evaluation Trial (MET trial). JAMDA. 2010;11(3):B9.
3. Husebo BS, Ballard C, Sandvik R, Bjarte Nilsen O, Aarsland D. Efficacy in treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomized clinical trial. BMJ. 2011;343:d4065.
4. Gauthier S, Wirth Y, Möbius HJ. Effects of memantine on behavioural symptoms in Alzheimer’s disease patients: an analysis of the neuropsychiatric inventory (NPI) data of two randomized, controlled studies. Int J Geriatr Psychiatry. 2005;20(5):459-464.
5. Pollock BG, Mulsant BH, Rosen J, et al. A double-blind comparison of citalopram and risperidone for the treatment of behavioral and psychotic symptoms associated with dementia. Am J Geriatr Psychiatry. 2007;15(11):942-952.

ALVEOLI

The alveoli

Alveoli are tiny grape-like sacs. There are two kinds of alveoli, those that exchange gases in the lungs, and those that turn blood into breast milk in the breast. The singular of alveoli is one alveolus.
"Alveoli {in the breast} are grape-like clusters of glandular tissue in which milk is synthesized from blood. Aveoli cells secrete milk. They are surrounded by a network of band-like myoepithelial cells, which cause the alveoli to contract when stimulated by the oxytocin released during the let-down, or milk-ejection, reflex. This action expels the milk into the ductules and down into the ducts."^[1]

"Air sac" redirects here. For other uses, see Air sac (disambiguation).

Alveoli in the lungs exchange oxygen with red blood cells when the heart's Sinoatrial and Atrioventricular nodes send electric signals to the hearts ventricles. The right side of the heart then contracts twice,^[source?] sending blood shooting into the pulmonary circulatory system, where capillary beds are located in the lungs. The Alveoli then exchange oxygen and discard carbon dioxide with the red blood cells, which then return to the heart's left atrium. When you breathe out, the body delivers carbon dioxide to the alveoli, and you release it in your exhalation. When you breathe in, oxygen fills the alveoli and then enters the blood, so it can be delivered to the rest of the body. In asthma there is no damage to the alveoli, which is different from another common lung disease which is called: chronic obstructive pulmonary disease, in which alveoli are damaged. A network of blood capillaries surround walls of each alveolus.The walls are extremely thin(one cell thick)and moist,thus allowing gaseous diffussion through them. There are over 300 million alveoli in each lung. If you were to spread one person's alveoli across a tennis court, they would cover over half the court!

This short article about science can be made longer. You can help Wikipedia by adding to it.

The alveoli also help for the lungs to keep out unwanted pathogens and viruses.

UTAH CNA CLASSES
UTAH CNA TRAINING
UTAH CNA SCHOOLS
SALT LAKE CNA TRAINING
SALT LAKE CNA SCHOOLS

NOTES FROM UNAR

Certification is required in Utah

CNAs are required by law to have a valid Utah CNA certificate prior to assuming nursing assistant duties.

There is one

exception:

If an individual works in a licensed nursing facility as an uncertified nursing assistant and is seeking initial

certification, he/she has four months (120 days) from the date of hire to obtain initial certification.

The 120 days is a onetime

only opportunity.

THE REGISTRY

****CNA training is valid for one year.

****All testing must be completed within 1 year from the completion date of training.

****All expired CNAs must test within 1 year from the certificate expiration date.

****CNA certificates must be renewed every two years

.

To qualify for renewal the Certified Nursing Assistant must perform paid services and provide proof of at least 200 hours

of

nursing or nursing related duties under the supervision of a licensed nurse for at least 200

hours at a Utah facility (during the two year period following certification)

. Renewal is two

years from

initial certificate issue date.

****

Renewal notices are mailed as a courtesy only, approximately 45 days before the renewal date

to the

last known address on file with the Registry. The candidate is responsible for the renewal

of their license.

****Do not rely on your place of work or anyone else to send in your renewal. Should your

license not be renewed in the allowed timeframe, you will need to pay for vouchers and retest.

The UNAR must be kept informed of your current address. If your address or name changes at any time after you

are placed on the Registry. You may call the registry with your new address or send us written notification. If it is

a name change, you will need to send supporting documentation, such as a copy of your social security card or

Utah drivers license, or a copy of your marriage certificate with your new name.

UTAH CNA CLASS
UTAH CNA TRAINING
UTAH CNA SCHOOL
UTAH TWO WEEK CNA CLASS
SALT LAKE CNA SCHOOL
SALT LAKE CNA TRAINING

UTAH CNA PASS RATE

Facility Totals ID# Written %%% Var. Skills %%% Var. Total %%% Var.
================================================== ==== ======= === ==== ======== === ==== ======== === ====
C C CNA 1054 125 97 +5 109 96 +5 136 78
================================================== ==== ======= === ==== ======== === ==== ======== === ====
PASS RATES FOR 2013. NOT AS HIGH AS I'D LIKE BUT 5% BETTER THAN THE AVERAGE. THAT'S NOT 97% PASS RATE FOR WRITTEN AND 96% FOR SKILLS


UTAH CNA PASS RATE
UTAH CNA CLASS
UTAH CNA SCHOOL