Gerontological Nursing INTRODUCTION TO GERONTOLOGIC NURSiNG Jose Karlo M. Pañgan,RN, MAN ` Week One
GERONTOLOGY Fromthe Greek word Geron, “old man The scientific study of the process of aging and the problems of aged persons; includes biologic, sociologic, physiologic, psychologic, and economic aspects
“Gero” – old age;“Ology” - study of Older Age Group: Young Old – ages 65-74 Middle Old – ages 75-84 Old Old – 85 and up.
TERMINOLOGIES Gerontophobia – fear of aging. Inability to accept aging adults in the society. Age Discrimination – emo-prejudice among the older adult. Ageism – dislike of the aging and the older adult.
Geriatrics– generic term relating to the aged, but specifically refers to medical care for the aged. SocialGerontology – concerned mainly with the social aspects of aging versus the biological or psychological Geropsychology – refers to the specialists in psychiatry whose knowledge, expertise and practice are with the older population.
Geropharmaceutics – also called Geropharmacology is a unique branch in which pharmacists obtain special training in geriatrics. Financial Gerontology – combines knowledge of financial planning and services with a special expertise in the needs of older adults.
Gerontological Rehabilitation Nursing –combines expertise in Gerontologic nursingwith rehabilitation concepts and practice.Gerontological Nursing – the aspect ofgerontology that falls within the discipline ofnursing and the scope of nursing practice.
ROLES OF THE GERONTOLOGICNURSE Provider of care Teacher Manager Advocate Research Consumer
DEMOGRAPHICS OF OLDPEOPLE “Graying of America” - a phenomenon faced by all nations, not only the U.S. Demographic Tidal Wave or A pig in a Python – a bulge in the population moving slowly through times. (1946-1964 : Baby Boomer)
DEMOGRAPHICS OF OLD PEOPLE By year 2010, the number of persons 65 and older in the United States is at 39 million: 13% of the population. By 2010- 2030, it is expected that 65 year olds will be more than 79 million. Women comprise the majority of the older population in all nations (55%), and the majority of these women (58%) live in developing countries.
Marital Status An important determinant of health and well- being, it influences income, mobility, housing, intimacy, and social interaction.
Gender Women live longer than men due to reduced maternal mortality, decreased death rate from infectious diseases, and increase death rate in men from chronic diseases. Women are likely to poor, alone, and greater degree of functional impairment and chronic diseases.
Living Arrangement andHousingA person’s overall degree of health andwell-being greatly influences theselection of housing in old age. Idealhousing promotes functionalindependence while emphasizing safetyand social interaction needs.
Geographic Distribution Older adults are less likely to change residence than other age-groups. “Aging-in-place”.
Education The educational level of older adult clients affects the nurse-client health teaching process and an important consideration in health promotion and disease prevention.
Income and Poverty Major source of income is SSS, and other supplemental income like assets, public and private pensions, earnings and public assistance. Income affects health and lifestyle – people are unable to meet basic needs and typically reduced the amount of spending in health-related matters.
EmploymentTwo-thirds of older, self- employed workers were men. The labor force participation of older men has remained fairly constant
Functional Status Functionalability is of greater concern to older adults and the nurses than the incidence and prevalence of chronic diseases.
Functional ability – the capacity to carry out the basic self-care activities that ensure overall health and well- being. ADLs: Bathing, Dressing, eating, transferring and toileting; InstrumantalADLs: shopping, cooking, housekeeping, laundry and handling money.
Nurseshould determine the plan of action on impact of chronic diseases. Improvement and Prevention are the keys.
Implications to Health Care Delivery Create roles that meet the needs of the older people, across the continuum of care Develop models of care directed at all levels of prevention with emphasis on primary prevention and health promotion services in the Community- Based Setting. Assume leadership, in health care and in political arena.
SETTINGS OF CAREAcute Care Setting Only few hospitals can adequately manage acute conditions by preventing functional decline: IMPLICATION persons.: hospital setting continues to be one of the most dangerous for older
The point of entry to the health care systems for older adults. Inthis setting, Gerontologic Nurses focus on treatment and nursing care of acute problems such as those occurring from trauma, accidents, orthopaedic injuries, respiratory ailments or serious circulatory problems.
Long Term Care/Nursing Facilities Include Assisted Living, Intermediate care, subacute or transitional care skilled care and Alzheimer’s unit.
Assisted Living / Home Care Provides an alternative for those older adults who do not feel safe living alone, who wish to live in a community setting or who need some additional help with the activities of daily living.
Intermediate Care Level of care provides 24 hour per day direct nursing contact and may be considered to be the entry level into the nursing home care.
Subacute or Transitional Care generally for patients who require more intensive nursing care than the traditional nursing home can provide but less than the acute care hospital.
Nurses Requirement Understanding of the normal and abnormal aging Strong assessment skills to detect subtle changes that may indicate impending, serious problems Excellent communication skills especially with DDD patients. Keen understanding of rehabilitation principles Sensitivity and patience.
LEADING CAUSE OF MORTALITY Heart Diseases Malignancies Cerebrovascular disease Chronic lower respiratory diseases Influenza and Pneumonia Diabetes Mellitus
LEADING CAUSE OF MORBIDITY Arthritis Hypertension Heart Diseases Hearing Impairments Cataracts Orthopedic impairments Sinusitis Diabetes
Theories of Aging Biological Stochastic and Non-stochastic Sociological Psychological
THEORIES OF AGING: I. STOCHASTIC THEORIES Based on random events that cause cellular damage that accumulates as the organism ages. II. NON STOCHASTIC THEORIES OF AGING Based on the genetically programmed events that cause cellular damage that accelerates aging of the organism.
I. STOCHASTIC THEORIESFree Radical Theory Membranes, Nucleic acids and proteins are damaged by free radicals which causes cellular injury, Exogenous Free radicals: Tobacco smoke, Pepticides, organic solvents, Radiation, ozone and selected Medications.
Health Teaching Decrease calories in order to lower weight Maintain a diet high in nutrients using anti-oxidants Avoid inflammation Minimize accumulation of metals in the body that can trigger free radicals reactions. Older adults are more vulnerable to free radicals.
Orgel/ Error Theory Errors in DNA and RNA synthesis occurs with aging.
Wear and Tear Theory Cells wears out and cannot function with aging. Like a machine which losses function when its parts wears off.
Connective Tissue Theory /Cross-linkage theory With aging, proteins impede metabolic processes and cause trouble with getting nutrients to cells and removing cellular waste products.
II. NON STOCHASTIC THEORIESOF AGINGProgrammed Theory/ HaylickLimit Theory Cells divide until they are no longer able to and this triggers to apoptosis or cell death. Shortening of the TELOMERES – the distal appendages of the chromosomes arm. TELOMERASE – an enzyme, “cellular fountain of youth”
Gene/ Biological Clock Theory Cells have a genetically programmed aging code.
Neuroendocrine control orpacemaker theory Problems with the hypothalamus- pituitary-endocrine gland feedback system causes disease. Increased insulin growth factor accelerates aging.
Immunologic/ AutoimmuneTheory Aging is due to faulty immunological function, which is linked to general well-being.
SOCIOLOGIC THEORIES OFAGING Attemptto explain aging in terms of behaviour, personality and attitude change.
SOCIOLOGICAL THEORIES changing roles, relationship, status and generational cohort impact the older adult’s ability to adapt.
Activity theory Havighurst and Albrecht (1953) Remaining occupied and involved is necessary to satisfy late life. Activity engagement and positive adaptation.
Disengagement Theory Cumming and Henry (1961) Gradual withdrawal from society and relationships serves to maintain social equilibrium and promote internal reflection.
Continuity Theory Havighurst(1960) also known as Development Theory Personality influences role and life satisfaction and remains consistent throughout life.
Age Stratification Theory Riley (1960) Society is stratified by age groups that are the basis for acquiring resources, roles, status and deference from others.
Lawton (1982) Function is affected by ego strength, mobility, health, cognition, sensory perception and the environment.Person-Environment Fit Theory
PSYCHOLOGICAL THEORIES OF AGING Explain aging in terms of mental processes, emotions, attitudes, motivation, and personality development that is characterized by life stage transitions.
Human needs Maslow’s (1954) Five basic needs motivate human behaviour in a lifelong process toward need fulfilment. Self – Actualization
Individualism Theory Jung (1960) Personality consists of an ego and personal and collective unconsciousness that views life from a personal or external perspective.
Stages of PersonalityDevelopment Erikson(1963) Personality develops in eight sequential stages with corresponding life tasks. The eighth phase, integrity versus despair, is characterized by evaluating life accomplishments; struggles include letting go, accepting care, detachment, and physical and mental decline.
Selective optimization withcompensation individuals cope with aging losses through activity /role selection, optimization and compensation.
GERONTOLOGIC ASSESSMENT Learning Objective: Explain the relationship between physical and psychosocial aspects of aging as it affects the assessment process. Special Considerations affecting assessment Interrelationship between Physical and Psychosocial aspects of aging. Nature of Disease and disability and their effects on functional status Tailoring the nursing assessment to the older person The health history Additional assessment measures
PRINCIPLES OF ASSESSMENT Use of an individual, person-centered approach View of clients as participants in health monitoring and treatment An emphasis on clients’ functional ability Note: Nursing-Focused Assessment should be scientifically based-knowledge and always practice to acquire the art of assessment.
Environmental factors Health Status
Effects of Selected Variableson Functional Status
Variable Effect Apathy Confusion Visual and Auditory Loss Disorientation Dependency Loss of Control Confusion Agitation Multiple strange and Dependency unfamiliar environments Loss of control Sleep disturbance Relocation Stress Mobility impairment Dependency Loss of Control Acute medical Illness Sleep Disturbance Pressure Ulcer Inadequate food intake Persistent confusion Drug Toxicity Potential for further mobility impairment Loss of functionAltered pharmacokinetics Altered patterns of bowel and bladder eliminationand pharmacodynamics Loss of Appetite: affects healing, Bowel function, energy level; dehydration Sleep disturbance
Problem Classic Presentation Elderly patientsUrinary Tract Dysuria, frequency, Dysuria often absent,Infections urgency, nocturia frequency, urgency, nocturia sometimes present. Incontinence, delirium, falls, and anorexia are other signsMyocardial Severe substernal Sometimes no chest pain,orInfections chest pain, atypical pain location: jaw, diaphoresis, nauseam neck, shoulder, epigastric dyspnea area. Dyspnea, may or may or may not be present. Tachypnea, arrtyhmia, hypotension, restlessness, syncope, and fatigue/weakness. FallBacterial Productive cough and Cough: productive, dry orPneumonia purulent sputum, chills absent; chills and fever and or and fever, pleuritic chest ↑ WBC may be absent. pain, ↑WBC Tachypnea, slight cyanosis, delirium, anorexia, NV, tachycardia.
CHF ↑ dyspnea,fatigue, ALL and/or anorexia, restlessness, weight gain, pedal delirium cyanosis, and falls.Cough. edema, nocturia, bibasilar cracklesHyperthyroidis Heat intolerance, fast slowing down (apathetic hypo), lethargy,m pace, exophthalmos, weakness, depression, atrial defibrillation, ↑ pulse, hyperreflexia, and CHF tremorHypothyroidism Weakness, fatigue, Often w/o over symptoms. Majority of cold intolerance, Cases Subclinical. Delirium, dementia, lethargy, skin dryness, depression/lethargy, constipation, weight and scaling, loss, muscle weakness/unsteady gait are constipation common.Depression Dysphoric Mood and Classic symptoms may or may not be thoughts, withdrawal, present. crying, weight loss, Memory and concentration problems, constipation, cognitive and behavioural changes, insomnia increased dependency, anxiety and sleep. Be alert for CHF, CA, DM, infectious diseases, and anemia. Cardiovascular agents. Anxiolytics, amphetamines, narcotics and hormones can also play a role.
2.2 NATURE OF DISEASE ANDDISABILITY AND THEIR EFFECTSON THE FUNCTIONAL STATUS
Aging does not necessarily result in diseases and disability Chronic diseases increases older adults’ vulnerability to functional decline Common Mistake: Nurses and adults attribute vague signs and symptoms as normal signs of “growing old”.
A comprehensive assessment ofphysical and psychosocialfunction is important because itcan provide valuable clues to adiseases’ effect on functionalstatus.
NursingAction: Identify NORMAL VS. ABNORMAL: dependable benchmarks of health are previous laboratory findings Watch out for vague signs and symptoms: do not ignore and look for non-specific signs.
2.2.1 Decreased Efficiency of homeostatic Mechanisms The older persons’ adaptive reserves are reduced- results in decreased ability to respond to physical and emotional stress. Immunocompetence is affected by multiple factors.
Adults repeatedly encounters losses: needs time to recover between losses and recuperation. The shorter time interval between losses, the lesser ability to respond and return to baseline stage of health compared to younger people.
Nursing ActionAssess older adults for presence of physical and psychological stressors and their physical and emotional manifestations.
Lack of Standards of Health and illness Difficultyarises on identifying the health status of older adults due to: Norms or standards are always redefined Polypharmacy and state of illness and disease may affect laboratory data. No aging norms for many pathologic conditions There are few landmarks for stages of development for the older adulthood compared to other age groups.
Nursing Action: Assume heterogeneity rather homogeneity: uniqueness of personal health standards. Look for previous health history and related matters: previous work, residence, lifestyle etc. Compare presenting signs and symptoms with the older adults’ normal baseline.
COGNITIVE IMPAIRMENT Delirium – one of the most common, atypical presentations of illness in older adults.
Confusion, mental status changes,cognitive changes and delirium –used to describe one of the mostcommon manifestations of illness in oldage.
Acute Confusional State (ACS)- an organic brain syndrome characterized by transient, global cognitive impairment of abrupt onset and relatively brief duration, accompanied by diurnal fluctuation of simultaneous disturbances of the sleep- wake cycle, psychomotor behavior, attention, and affect”( Foreman, 1986)
Dementia – a global, sustaineddeterioration of cognitive function inan alert client.Other manifestations: memoryimpairment, aphasia, apraxia,agnosia, or disturbance in executivefunctioning; planning, organizing,sequencing and abstracting.
Primary dementiaSenile dementia of Alzheimer’stype, Lewy body disease, Pick’sDisease, Creutzfeldt-JakobDisease and multi-infarctdementia
Secondary DementiaNormal pressure Hydrocephalus,intracranial masses or lesions,pseudodementia, and Parkinson’sdementia.
Differentiating Dementia and ACS FEATURE ACS DEMENTIA Acute/subacute; depends Chronic, generally insidious; on cause; often occurs at depends on causeONSET twilight Short, diurnal fluctuations, Long, no diurnal effects, worse at night, dark and symptoms progressive, stableCOURSE awakening Hours to less than 1 month Months to yearsDURATION Fluctuates, generally Generally ClearAWARENESS reduced
Fluctuates, reduced or Generally normalALERTNESS increased Impaired, often fluctuates Generally normalATTENTION Fluctuates, in severity, May be impairedORIENTATION impaired Recent and immediate Recent and remote memory impaired; unable to memory impaired; loss of register new information or recent memory is 1 st sign;MEMORY recall recent events some loss of common knowledge Disorganized, distorted, Difficulty with abstract andTHINKING fragment, slow, or word finding accelerated Distorted, illusions, delusions, Misperceptions oftenPERCEPTION or hallucinations absent Disturbed, cycle reversed FragmentedSLEEP-WAKECYCLE
TAILORING THE NURSING ASSESSMENT TO THE OLDER PERSONS Environmental suggestions during assessment of the older adults Provide adequate space, especially if client uses mobility aids Minimize noise and distractions Set a comfortable, warm temperature with no drafts. Use diffuse lighting. Avoid glossy or highly polished surfaces.
Place client in a comfortable position Maintain proximity to the bathroom Keep water and other preferred fluids available Provide a place to hang or store garments and belongings Maintain absolute privacy
Plan the assessment: consider client status Be patient, relaxed and unhurried. Allow client plenty of time to respond to questions and directions. Maximize use of silence. Be alert to signs of increasing fatigue. Conduct assessment during client’s peak energy time.
THE HEALTH HISTORY The first phase of a comprehensive, nursing-focused health assessment, provides a subjective account of the older adults’ current and past health. The nursing history should include assessment of functional, cognitive, affective, and social well-being. The interviewer should adapt the styles and techniques of interview in the
THE INTERVIEWERFactors to consider during nurse-clientcommunication during assessment Attitudeof nurse Myths and Stereotypes about older people Nurse’s own anxiety and fear of personal aging
Guide to an effective interview State reason for the interview Let client accomplish a pre interview form A goal-directed interview process Setting of time limit
Secure permission to take down notesObserve most effective and comfortable distance and position, and personal space for the sessionAppropriate use of touchTake advantage of opportunities such as meal time, game, hobby, and other social activity.
THE CLIENT There are factors the nurse should consider while interviewing an older adult such as: Sensory-perceptual deficits Anxiety Reduced energy level Pain Multiple and interrelated health problems The tendency to reminisce
THE HEALTH HISTORY FORMAT Client Profile/ Biographic data Family Profile Occupational Profile Living Environment profile Recreation/Leisure Profile Resources/Support systems used
THE HEALTH HISTORY FORMAT Description of typical day Present health status Medications Immunization and health Screening Status Allergies Nutrition Past Health Status Family History Review of Systems
SYMPTOM ANALYSIS FACTORS Dimensions of a Symptom Location Quality Quantity Timing Setting Aggravating or Alleviating factors Associated symptoms
THE PHYSICAL EXAMINATIONAPPROACH AND SEQUENCE Should be systematic and deliberate Determine client strengths and capabilities; disabilities and limitations Verify and gain objective support Gather objective data not previously known
GENERAL GUIDELINESRecognition of no previous experience with the nurse conducting physical examination by the adultBe alert on the clients energy levelRespect the client’s modestyKeep the client comfortably drapedSequence examination to keep position changes to a minimum
Develop an efficient sequence for examination that minimizes nurse and client movementEnsure comfort for the clientWarn of any discomfort that may occur. Be gentleProbe painful areas lastShare findings with the client when possibleTake advantage of teachable momentsDevelop a standard format on which to note selected findings.
EQUIPMENT AND SKILLS Check proper function and readiness of all equipment Place equipment within reach Use of Inspection, Auscultation, Palpation, and Percussion.
ADDITIONAL ASSESSMENT MEASURES Functional Status Assessment – refers to the measurement of the older adults’ ability to perform basic self-care tasks, or ADLs, and task that require more complex activities for independent living referred to as IADLs.
KATZ Index of ADLs – Determines results of treatmentsand the prognosis in older andchronically ill people.
Barthel Index – tool for measuring functional status, rates self-care abilities in the areas of feeding, moving toileting, bathing, walking, propelling a wheelchair, using stairs, dressing and bowel and bladder control
Lawtonand Brody’s IADLs – a range of activities more complex than KATZ and Barthel. Usage of telephone, shopping, preparing food, housekeeping, laundry, meds, transporting and finances.
Cognitive/AffectiveAssessment assesses level of cognitive function and the effect of the assessed degree of impairment on functional ability
Short Portable Mental StatusQuestionnaire (SPMSQ) – used to detect the presence anddegree of intellectual impairment toassess orientation, memory in relation toself-care ability, remote memory andmathability.
MiniMental State Examination – tests the cognitive aspects of mental function: orientation, registration, attention, and calculation, recall and language
Mini-Cog - an instrument that combines a simple test of memory with a clock drawing test. Geriatric Depression Scale - a score of five (5) or more may indicate depression
Social Assessment – (1) Social function is correlated withphysical and mental function, (2) anindividual’s social well-being canpositively affect his or her ability tocope with the physical impairmentsand ability to remain independent, and(3) a satisfactory level of social functionis a significant outcome in and of itself.
Family APGAR – Stands for: Adaptation, Partnership, Growth, Affection and Resolve. Older Adult Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire - a social resource scale, one of the better- known measures of general social function for older adults