Geriatric

1. GERIATRIC
NURSING
BY
Mr. Njenga

2. Course objectives
Broad objective
• The student will acquire knowledge, develop skills and
attitudes in order to provide care for the elderly persons.
Specific objectives
1. The student will be able to describe the role of the
KRCHN with regard to health promotion in the care of
the elderly.
2. The student will be able to assess elderly persons and
diagnose deviations from normal
3. Review of growth and development
4. Review the ageing process
5. Review the grieving process
6. History taking in the elderly
7. Physical examination of the elderly

3. COURSE ASSIGNMENT
• In four groups discuss life taking reference to
the developmental stages of life under the
following theories:
– Attachment theory
– Constructivism
– Ecological systems theory
– Psychosexual development
– Stages of moral development
– Stages of psychosocial development
– Stages based on the model of hierarchical complexity
– Theories of cognitive development
– Zone of proximal development
– Nature and nurture

4. Definition of terms
• Gerontology: a branch of science that deals with aging and
problems of the aged people.
• Geriatrics: is the study of medical aspect of old age and
application of the knowledge related to biological, biomedical,
behavioral and social aspects of aging to the prevention and
care of the elderly person.
• Aging: total time related changes experienced by an individual
which are biological, psychological, sociological and spiritual.
– Slowing of body processes affecting a variety of functions
• Ageism: a process of systematic stereotyping and discrimination
against old people because they are old.
• Gerontophobia: unreasonable fear and irrational hatred of older
people
• Age: the length of time that has passed since birth.
• Types of aging: feel age, identity age, cognitive age, perceived
age, or self perceived age

5. • Life expectancy: statistically determined number of years that a
person at a particular age may expect to life.
• Lifespan: longest period of life of an organism known from the study
of it.
• Biological clock: each cell is believed to be programmed through the
DNA to self-destruct i.e. contain cells that are known to multiply and
divide a fixed number of times and then self-destruct.
• Aging pacemaker: pacemaker in the brain initiates a neuro-hormonal
response possibly through serotonin, dopamine neurotransmitter or
tryptophan that results in aging.
Stages of aging
– 55 – 65 young old
– 65 – 75 middle old
– Over 75 years old old
Challenges of old age
– Retirement
– Widowhood
– Chronic illness
– Relocation e.g. to rural areas

6. Aging
Def: The total time related changes experienced by an individual
which are biological, psychological, sociological and spiritual.
Types of aging
• Biological aging: refers to changes in structure and functions of
the body that occur over a lifespan. It can be gradual affected by
genetic inheritance, external and internal environmental factors.
• Psychological aging: behavioral changes in self perception and
reaction to biological changes. It is influenced by conditions of
the body e.g. cardiovascular or renal system; changes in the
brain that may affect memory, learning, motivation and emotions.
• Functional aging: refers to capacity of the individual to function
in society compared to that of others in the same age group.
• Sociological aging: changes in roles and social habits of
individuals in the society. It includes: changes in expectation and
social status

8. Aging theories
Biological theories
a) Genetic theory: Programmed theory of aging by Hayflic 1960.
he says that:-
• Lifespan of animals is pre-determined by a genetic programme.
Biologic clock of humans has a maximum of 110 years.
• Normal human cells divided about 50 times after which they
stop dividing and shrink and die.
b) Mutation theory: states that aging is as a result of mutation of
somatic cells or alteration of DNA repair mechanism. In effect,
aging is caused by an assortment of genetic diseases, each of
which has adverse symptoms only at advanced ages.
c) Wear and tear theories: says that organs have limited or fixed
amount of energy available and will wear out on a scheduled
basis. When enough cells wear out , the body does not function
well. This process is made worse by:-

9. • Harmful stress factors e.g.
– smoking,
– Poor diet
– Muscular strain
– Large intake of alcohol
• Theory is supported by-:
– Microscopic signs of wear and tear in Striated skeletal
muscle, heart muscles and nerve cells
• The body is likened to a machine that works well in a
specified period but will eventually fail due to wear
and tear.
d) Immunity theory: it is based on knowledge that
immune system particularly the thymus and the
immuno-component cells of the bone marrow are
affected by the aging process.

10. • Older people have fewer defense mechanism against foreign
organism. They are more susceptible to disease e.g. cancers,
infections.
• Their body also has increased auto-immune responses, i..e.
the body reacts against itself producing antibodies against its
cells. It also develops antibodies against food, foreign bodies,
etc.
• This may explain development of autoimmune disease like
lupus, diabetes, rheumatoid arthritis e.t.c
e) Cross-linkage theory: it states that normally separated
molecular structures are bound together through chemical
reactions. Cross-linkage agent attaches itself to a single strand
of a DNA molecule and destroy it.
• In normal circumstances natural body defense mechanisms
would repair the damage. In old age the defense mechanism is
weakened. Cross-linkage continues until organs are damaged
and end results are mutation of cells that do not function.

11. f) Free radical theory by Harman 1956: protective
mechanisms to free radicals decline with age. Due
to force on poly-unsaturated fats in the cell,
unstable free radicals are released and peri-
oxidised resulting in destruction of cell structures.
Vitamins E, C and serotonin (anti-oxidants) inhibit
the production of free radicals and thus delay
aging. With age when the free radical molecules
attack other cells they damage the cell membranes
leading to aging due to accumulated cell damage.
Eventually this leads to organ failure or
• Free radical theory: it proposes that aging is
caused by increased levels of highly unstable
molecules called free radicals.

12. • These particles are produced by normal
metabolism, exposure to radiation, pollutants
or to other free radicals. Free radicals disrupt
or damage normal cells and their genetic
materials. Eventually this leads to aging and
the death of cells. Free radicals cause
building up of fatty pigment granules called
lipofuscin resulting in age spots.
g) Other biological theories: proposes that
hormone changes, neurotransmitters levels or
viruses are responsible for the changes in
aging. No biological theory completely
explains aging

13. Psychosocial theories of aging
• These don’t explain why aging occurs but rather attempt to explain why
older adults have different responses to the aging process.
a) Disengagement theory: it explains why aging persons separate from
mainstream of society. It proposes that older people are systematically
separated or disengaged from society because they do not benefit
society as a whole. It further says that elderly persons desire to withdraw
from society as they age, so that the disengagement is of mutual benefit.
b) Activity theory: it proposes that activity is necessary for successful
aging. Active participation in both physical and mental activity helps in
maintaining functioning into old age. Purposeful activities and
interactions leads to improved self esteem and overall satisfaction with
life even at an extended age.
c) Continuity theory: it states that an individuals characteristic coping
strategies are in place long before old age but personality features are
also dynamic. Using this theory the best way to predict how a person will
adjust to old age is to examine how the person has adjusted to other
changes in life.

14. d) Sub-culture theory by Rose 1962 – 1965: it states that
old people as a group have their own norms, expectation,
beliefs and habits therefore they form a sub-culture. They
are less integrated to the society and more integrated
among themselves. This serves in improving self image of
older people and reduces cultural negative view of aging.
e) Age stratification theory: its based on beliefs that:-
– Individuals pass through the society in cohort of age, social,
biological and psychological.
– New cohorts are continuously being born with unique sense of
history.
– Society itself is continuously changing as are the people and
their roles in each strata.
– Society can be divided into various strata according to roles and
age.
– There is a dynamic interplay between individual aging and
change.

15. f) Personal environment fit theory by Lawton
1985: it states that aging is as a result of
interrelationship between personal competence
and environment which is a potential for eliciting
behavior from individuals towards and
includes:-
– Ego strength
– Motor skills
– Biological health
– Cognitive capacity
– Sensory perception

17. Normal physical changes that occur in
old age
Cardiovascular changes
• The heart: the heart muscles become rigid i.e. they loose elasticity and
contract poorly. This affects the output of the heart especially when the
person performs activities e.g. walking or any other exercise.
– There is a misplacement of the apex of the heart caused by the back of the
old person being bent (kyphoscoliosis). If you place a stethoscope on the
normal area you will miss the apex beat.
– Murmurs: most of the aged persons have a diastolic heart murmur heard at
the base of the heart. It is due to the hardening of the aortic valve.
– Heart rate: does not change with age.
• Arterial circulation: Arteries become rigid increasing resistance to the
blood flow. This causes a rise in blood pressure in the aged.
• Venous circulation: this does not change with age unless the person is
sick.
• Blood pressure: significant increase in systolic, slight increase in diastolic,
increase in peripheral resistance and pulse pressure.

18. • Peripheral blood vessels: they are easy to palpate because
of increased arterial wall narrowing and loss of connective
tissues. They feel more tortuous and rigid. This causes the
extremities of the old people to be cold especially at night and
they also get discolored.
• Other conditions associated with the heart and blood vessels
in old age are; hypertension, congestive cardiac failure,
myocardial infarction, arteriosclerosis, thrombo-phlebitis
Respiratory system changes
• Pulmonary flow and diffusion: There is decreased blood flow
leading to poor gaseous exchange in the lungs, thus decreased
diffusion.
• There is increased in residual lung volume
• Reduced vital capacity and decreased cough reflex.
• Anatomic structure: increased anterior-posterior diameter
• Respiratory accessory muscles: degeneration and decrease
strength; increased rigidity of the chest wall

19. Integumentary changes
• Texture : skin looses elasticity, wrinkles and becomes
drier. It is cooler to touch and there is reduced sweating.
• Fat distribution: there is less on the extremities but
more on the trunk.
• Hair color: white or grey in color. Hair distribution is thin
on the scalp. Women may develop chin and lip hair
• Nails: there is decreased growth rate
Genito-urinary system
• Kidney function: there is reduced glomerular filtration
rate due to deceased cardiac output. There is loss of
protein due to renal inefficiency.
• Renal blood flow: due to decreased cardiac output,
reduction in the filtration rate and renal efficiency.
Subsequent loss of proteins from the kidneys may occur.

20. • Micturition: men- the frequency may increase due to
prostatic enlargement. Women: urgency and stress
incontinence due to increased perineal muscle tone.
Nocturia increases for both men and women. With
advanced age incontinence increases.
Reproductive system
• Female: there is reduction in estrogen causing atrophy
of the breasts, ovary, uterus, and epithelial lining of the
vaginal wall. The vaginal canal narrows and shortens.
vaginal secretions reduce and become more alkaline
leading to increased rate of vaginitis.
• Men: there is a decrease in the production of
testosterone leading to decreased sexual drive and
lowered fertility. Testes decrease in size, sperm count
decreases; and viscosity of seminal fluid diminishes.

22. Musculoskeletal changes
• Muscles: there is decreased muscle mass all over the body
leading to reduced physical strength.
• Bones: there is reduction in calcium and phosphorous causing the
bones to be porous and weak. There is shortening in height due to
intervertebral space narrowing.
• Joints: the joints become less flexible and less mobile and there
is reduced range of movements.
Digestive system
• There is partial or total loss of the teeth and malocclusion leading
to impaired mastication.
– Swallowing is more difficulty as salivary secretions diminish and
therefore old people prefer soft diet.
– Digestion is decreased due to reduced production of digestive enzymes.
– Sluggish peristalsis due to reduced gastrointestinal motility leading to
constipation.
– Esophagus: there is decreased esophageal peristalsis. Increased
incidence of hiatus hernia with accompanying gases distention

23. Nervous system
• There is general decrease in the ability to respond to stimuli.
– Reflexes are slowed.
– There is decline in ability to learn new skills and experiences.
– Older people forget easily . Preservation of memory of past
experiences is good. Older people have difficulties making decisions.
They have difficulties in remembering immediate or recent events.
• Sleep: the elderly stay in bed longer but sleep less.
• Vision: it decrease in accommodation due to hardening of the
lens and this requires collection of the lens.
– The lens may develop opacity and cataract formation.
– There is decreased lacrimation leading to frequent infection of the
eyes
– There is inability to adapt to darkness resulting from presbyopia.
– There is diminished color perception due to loss of cones in retina
– Sunken appearance of the eye due to loss of orbital fat.

24. • Hearing: there is progressive decrease in auditory
threshold( ability to hear many sounds decrease
especially higher frequencies). The reduced ability to hear
causes a sense of suspiciousness to develop in some old
people.
• Smell: there is some decline in sensitivity to usual smells.
• Taste: there may be decrease in the number of taste
buds on the tongue causing an increased complaints
about food.
• Touch: there is decreased sensitivity with age but the
sense does not diminish. Reduction in flexes and reaction
time. Altered ability to adapt to environment. Increased
pain threshold.
• Propioception: there is impaired perception of position
and relationship to space affecting balance and
coordination.

25. Review of growth and development
Def: the process by which the fertilized ovum
attains adult status.
• Growth: implies change in size and values
given certain measurements of maturity.
• Development: other differentiation of form or
function including emotional, social and
psychological shaped by interaction with the
environment.

26. Factors affecting growth and development
• Genetic/heredity factors: is the passing on of
characteristics from parents to children.
• Trauma: prenatal or post natal, either chemical or
residual from infections, physical or immunological.
• Nutrition: the body needs different kinds of nutrients for
growth, energy and repair.
• Social and emotional factors e.g. position of a child in
the family, interactions with parents, child rearing
practices, person concerns and needs of parents.
• Cultural and political expectations: The body growth
differences correlate with varied cultural groups. The
physical growth of the body follows some adaptations in
different geographical areas of distribution of the groups.

27. • Socio-economic factors: Children from
different socioeconomic levels differ in average
body size at all ages. Size of family exerts an
indirect influence on the rate of growth. In a
large family with limited income the children do
not get proper nutrition. As a result the growth
is affected.

28. Review of growth and development ctnd…
• This is a continuous process that begins at conception.
Immediately following conception mitosis occurs or cell
division starts. The cells continue subdividing forming a
cluster of cells. These cells assume highly specialized
functions becoming part of various body systems.
• Similar cells group together to form tissues, organs,
organ systems e.g. nervous system.
• The fetus begins to take shape. The sequence of
development in the prenatal period is fixed. i.e. at
different stages in-utero life certain organs should be
developed.
• Growth and development is a continuous process which
extends from time of conception to the time of death.

30. Stages of development
• At birth: weight is at an average of 3.5 Kgs. Baby
communicates through crying, baby is able to suck,
swallow and have fine movements. Length is
approximately 50 cms and head circumference is 33 to 36
cm.
• 1 month: baby keeps quiet when talked to.
• 2 months: baby smiles, responds, vocalizes when talked to
and lifts up the head to follow objects.
• 3 months: baby is able to follow objects.
• 4 to 5 months: baby is able to roll from the abdomen to the
back, plays around with hands and can sit with support.
• 6 to 7 months: baby double the birth weight and can sit
unsupported.. Holds objects tightly. He/she is a little
possessive due to mental and physical development

31. • 8 to 9 months: some crawl, some standing and falling.
• 12 months: can recognize familiar sounds, walks without
support though falling and can respond to simple
commands. E.g. bring a spoon or cup. The baby triples
birth weight
• 18 months: walks without support and can make some
words about 6 to 20. Anterior fontanelle closes.
• 2 years: can run steadily. Bladder sphincter muscle
control is achieved. Can make sentences while talking
and has full developed sight and can see things the way
they are. Knows the members of the family.
• 21
/2 years: teeth up to 20. the child is able to undress.
He/she has a feeling of self-centredness and self
concept.

32. • 3 years: the child is able to jump and climb
stairs. He/she is active and talks a lot.
• 4 years: child can feed himself and needs
others to play with. Pre-school age.
• 5 to 6 years: less dependent and can play
mother and father games. Can dress and
undress. He/she is less destructive and can
concentrate on group learning. Milk teeth begin
to fall off and are replaced by permanent teeth.
• 7 to 9 years: there is rapid increase in weight
( 2 to 2.5 kgs. per year)

33. • 9 to 12 years: rapid weight gain. Hormonal effect on sex
organs. Early adolescence; the child learns better in
school. The children identify themselves better with
children of the same sex . They have less sexual
interest. Girls may develop faster than boys. During this
stage the children acquire roles as per their parent. They
develop attitudes and socio-cultural values of the society.
• 12 to 18 years:
• Girls: increase in size and body tissue (breasts grow).
There is increase in appetite and onset of menarche.
Development of secondary sexual characteristics.
Develop acne. They are attracted to the opposite sex
and develop rebellion to family members. They admire
themselves and are very cautious of their shape and
self-image.

34. • Boys: beard grows, the voice breaks and they nocturnal
emissions. They have a tendency to masturbate. They love
exploring the environment with peers e.g. discos, night
clubs etc.. All secondary sexual characteristics develop.
• 18 to 25 years: rapid growth settles. They start thinking of
their future carriers and are more responsible in their
relationships. They are less conscious of their weight.
Some girls marry. They show more concern with other
members of the family.
• 25 to 30 year: young adulthood. Look at situations
reasonably. They are very sexually active at this stage
especially females. Most of them are married with
responsibilities. They change in their friendship patterns to
developmental groups and changed roles, e.g. nurses,
teachers etc.

35. • They are at highest of their physical powers. Males
are more concerned with success and results. They
are mobile.
• 30 to 45 years: they undergo a critical stage
• Females: they become drunkard or chronic shoppers.
Women living in poverty become depressed and want
to keep visiting relatives (involutional melancholia).
• Male: bald head, deposition of fat and grey hair. They
tend t be afraid of losing sexual potency and they want
to run after girls. Some may get second wives. A man
who ahs attained success work even harder. Those
unsuccessful tend to despair and if one has been a
drunkard, they tend to drink more. Those in better
position would like to retire at 45 years.

36. • Women from the age of 46 undergo
menopause. Some are sexually active while
others are not. At age 55 most start to undergo
degenerative changes.

37. Stages of old age
• Stage 1: 55 to 65 years; late adulthood which is a
culmination point for most middle class adults.
Responsibilities are more or less stable up to the time
of retirement. Financial pressures have eased. Late
adulthood is refereed to as the “ stage of the empty
nest”. Children have left home or are leaving. It is time
to prepare for retirement and post-retirement life.
• Stage II: 65 to 74 years; This is the retirement age for
most people in the western world. Income drops to half
what they used to earn. More health problems and
chronic illness. Death is a more frequent visitor.
Decade when many women loose their spouses.
Friends are lost either due to death or migration to rural
areas.

38. • It is not easy for old people to make friends.
Many older people are unable to care for
themselves despite preparation and financial
security made earlier. This is mainly due to
more health problems thus becoming
dependent on the state or their relatives.
• Stage III: 75 years and over; this is the stage of
dependency. The old person experiences
infirmities and chronic conditions. Signs of
aging are more evident and the scope of life is
more focused. The person focuses on a few
significant relationships. The person comes to
term with his own death.

39. Tasks for old people
1. Getting along with children and younger or
older grandchildren.
2. Dealing with own death.
3. Desire to leave a legacy e.g. children, money,
works of art, writing, personal possessions.
4. The older role- the old people enjoy
accumulated knowledge, experience and
wisdom with the young.
5. They have attachment to familiar objects
6. They have changes in the sense of lifestyle,
creating curiosity and surprise.

40. Abnormal conditions common in aging
• Integumentary conditions
– Basal cell carcinoma: common in older persons who
have spent a lot of time in the sun. Note any pigmented
area that is enlarging and is elevated from the skin. It
bleeds easily when touched.
– Decubitus ulcers: caused by shrinkage of subcutaneous
tissue that normally cushions the skin over the bony
prominences. The skin of the aged person has a greater
risk of breakdown. Extra care should be taken of elderly
people who are bed-ridden or confined to wheelchairs.
– Hypothermia: occurs due to decreased subcutaneous
tissue and fat especially in very thin elder persons. Care
should be taken not to expose the older person to
extremes of the environment.

41. • Musculoskeletal system conditions
– Osteoporosis
– Degenerative joint disease
– Rheumatoid arthritis
– Bursitis
• Respiratory system conditions
– Chronic obstructive pulmonary disorders e.g.
emphysema, asthma, chronic bronchitis
– Influenza
– Pneumonia, aspiration pneumonia
– Tuberculosis
– Lung cancer

42. • Conditions affecting the CVS
– Coronary artery disease, coronary valve disease,
heart block, CCF, peripheral vascular disease
(arteriosclerosis), occlusive peripheral vascular
disorders (thrombosis formation, thrombo-phlebitis,
embolus), varicose veins, aneurysm, hypertensive
disease.
• Hematopoietic and lymphatic system
• Physiologic changes
– Increased plasma viscosity leading to increased risk
of vascular occlusion
– Decrease in RBCs production leading to increased
incidence of anemia.

43. – Increase in immature T-cells leading to
decreased immune response

44. Conditions affecting the sensory system
• Hearing: deafness (temporary or permanent)
– Conductive hearing loss
– Nerve deafness
– Mennier’s disease…..xterised by severe vertigo,
nausea, tinnitus
• Sight: blindness (partial or total)
• Taste and smell: reduced sensation of sweetness
Conditions affecting endocrine system
– DM, hypoglycemia, hypothyroidism
Conditions affecting the reproductive system
– Prolapse of the uterus, vaginal infections, breast
cancer, prostate cancer

45. MEDICATION AND THE ELDERLY
Pharmacokinetics
Absorption
Oral medication
• There is reduced gastric acid and enzymes with aging resulting in
increased gastric PH. Most medication is designed to dissolve in acid
medium, neutral or alkaline gastric results in decreased absorption.
• Decreased gastric motility leads to slower emptying rate of stomach
content. It results in increased length of time. Medication is in contact
with stomach lining leading to increased absorption and wearing of
the stomach lining.
• Decreased peristalsis leads to delaying transportation and delayed
action.
• Changes in cells ability to absorb and transport drugs influence
absorption.
• Transfer of medication in cells membrane

46. Distribution
• Aging causes
– A decrease in total body mass
– A decrease in total lean body mass
– Decrease in body water
– Increase in total body fat
thus interfering with distribution of drugs
• Water soluble drug e.g gentamycin, remains in the blood
stream longer with high concentration especially with
dehydration.
• With increased total body fat; it leads to fat soluble drugs
being trapped in body fat reducing levels of the drug in
blood stream.
• There is reduced H.b and plasma protein in elderly person
leading to decreased available sites for protein bound drugs
such as warfarin.

47. Metabolism
• There is decreased enzyme production that leads to reduced function
resulting in decreased cardiac output.
• There are circulatory changes with reduced blood flow to the liver.
• There is reduced liver effectiveness and speed of metabolism of
drugs. Risk of toxicity increases especially in the elderly.
Excretion
• Kidney function is decreased. Drug levels in the blood stream
increases leading to toxicity.
• Reduced blood flow to the kidney leads to increased toxicity risk.
Medications such as digoxin lithium. Cimetidine can diminish renal
function and cause retention of other medication.
• Alcohol and nicotine affects drug elimination in the elderly person.
• Risk increase with multiple medication.
• Polypharmacy i.e. use of excessive often unnecessary is a common
problem with the elderly with prescription during and over the counter
drugs resulting in cognitive or behavioral inability.

48. Care of the elderly persons
Care in the community
Family:
• planning of care is done with family as major care givers. In
case of dependency the spouse becomes the primary
caregiver. If no spouse is available, then a child becomes the
primary caregiver.
• Adult children assume responsibilities for their parents and
provide financial, social, psychological support to their aged
parents.
• Despite the care and support provided by children strains
usually appear if care is given over a prolonged period.
• The child-parent relationship declines especially if the parents
are in poor health and cold lead to elder abuse with physical
violence, personal neglect, financial exploitation, violation of
rights, denial of healthcare and self inflicted abuse.

49. • Caregivers require professional health in the care of the elderly
persons who should explain the aging process and tell the caregivers
what to expect.
• Independence of the elderly person should be encouraged as long as
possible.
Home environment
Safety and comfort
• Accidents e.g. falls should be avoided.
• Falls are caused by physical changes in aging e.g. failed vision, loss
of depth perception, loss of balance and cardiovascular change.
• The home should have adequate lighting and minimal glare.
• Supportive bars should be provided in bathrooms
Personal space
• Older persons need space of their own where they can get privacy
and comfort. This can be a house, room or part of a room. In this
space the elder person can keep treasures acquired in a lifetime.
• If she/he is moved another space should be provided and the person
should be allowed to hold, touch and enjoy his treasures.

50. Nutritional needs
• Nutritional needs must be met to prevent the body
from deteriorating further.
• 1 person needs at least 1 gm of protein per kg
body weight added if the person is sick.
• Old people may not experience hunger due to
poor taste perception and slowed activity.
Nutrients are absorbed slowly and since most
people live alone they may fail to cook.
• They should be encouraged to cook food rich in
protein, carbohydrates, minerals, vitamins to meet
body requirements and they should take
adequate fluids.

51. • Food should be soft so that the old person can
use his denture to chew. It should also be soft
since sometimes they may have problem with
swallowing.

52. Elimination needs
• Old people are pre-occupied with their bowel functions
and they require reassurance that daily bowel movements
may not be necessary.
Constipation
• Many old people require stimulation to keep their bowels
functioning. Some may require laxative or stool softener
but care should be taken that an old person does not use
them daily and think that he/she cannot do without them.
• Clients should be encouraged to exercise regularly, eat
fruits and vegetables and drink plenty of water.
Bladder and bowel incontinence
• The older person may have difficult in controlling bladder
and bowel function. To overcome this, the older person
should be retrained to be following regular schedules.

53. • Retraining is usually welcome since it saves the person
from embarrassment.
• To start with trips to the bathroom should be short interval
which should be gradually lengthened. Catheters should be
avoided as they also introduce infection to the urinary tract.
Difficult in voiding
• Retention of urine is common in the older people (men)
due to enlargement of the prostate gland. Corrective
surgery should be organized . Urine output also decreases
due to reduction in the glomerular filtration rate.
Physical hygiene needs
• Skin care: Skin is more delicate and requires better care
to avoid infection or breakdown due to pressure. If the
older person is incontinent of either urine, stool or both,
care should be taken to keep him clean and dry.

54. • Skin oil or lotion should be used to keep the skin soft
and promote peripheral circulation.
• The older person sweat and oil glands are less active
so the person can take a bath less often and should
use bath oil or mild soap.
• Oral hygiene: Older person should be encouraged to
take care of the mouth and take care of the dentures.
• Hair: should be kept clean and tidy
• Nails: finger nails are hard and brittle, so should be
kept soft by being rubbed with lotion or being soaked
in warm water. Should be cut and kept short.
• Shaving the male: assist the older person to shave
their beard regularly and ensure their safety.

55. • Safety: loss of Propioception (sensation of body space).
Restrains e.g. side rails in beds, adaptive devices for bath
tabs and toilets.
• Communications: older people experience problems
communicating due to their failing sensory system. The is
need to be encouraged to communicate and where
possible they should not be kept alone in a room.
• Hearing loss (presbycusis): starts at 40 and progresses
with age. Older people who are hard of hearing should be
assessed and mechanical aid should be provided.
• Vision impairment; presbyopia: impaired vision due to the
aging process. Aids for visually impaired should be
provided e.g. large prints in telephone numbers,
magnifying glass, spectacles, more night light to help in
night blindness.

56. • Physical activities and exercise: activity and
exercise are very important to the older person
to maintain circulation, muscle tone, general
health and to prevent deformities that may
occur in disease.
• Emotional support and mental stimulation:
the elderly person should be encouraged to
remain self-sufficient and mentally active. This
will prevent the person from boredom and
depression. The older should be allowed to
make decisions affecting his care.

58. Mental health problems of the aged
1. Anxiety: it is a major problem of the aged due
to the threats of their self esteem and image.
The older person anticipates losses of health
independence, familiar home, family contact
and life itself.
• The anxious person can be withdrawn, isolated,
confused, combative or have any other mal-
adaptation behavior.
2. Depression: it is the most common disorder in
the elderly person affecting about 50%. Most
persons may end up in suicide.

59. • Causes of depression in the elderly
– Chemical imbalance
– Living at or near poverty level.
– Loss of spouse and friends leading to loneliness.
– Serious physical illness and debilitating disease.
– Poor nutrition
– Lack of exercise
– Over-sedation
– Lack of mental stimulations
• Management: where the cause of depression is
known, alleviating the cause may help.
• NB: antidepressant drugs have adverse side
effects on elderly persons and the nurse should
observe. Dosage should also be reduced.

60. 3. Chemical dependency
• Alcohol: it is a special problem with the elderly. Reasons for
alcoholism in the elderly person are; loneliness, boredom.
• Mngt: gradual withdrawal
4. Abuse of prescription drugs
• Self medication, visits different doctors with different prescriptions
• Mngt: education on proper use of drugs, explanation about side
effects
Therapies aimed at emotional and psychological support to the
elderly
– Re-motivation technique
– Recreation
– Learning
– Social life and activities
– Pet therapy
– Religious support
– Mental therapies

61. Drugs and the elderly
• Elderly people use more drugs than any other age group in
the community. This leads to more adverse reaction
occurring in the elderly people since they are normally
failing e.g. eyesight cause the elderly to make mistakes in
their medication.
• Physiological consideration of their failing functioning
should be put into consideration while prescribing drugs.
• The liver and the kidney may not be able to synthesize and
excrete drugs. Age related changes in the function of CVS,
gastrointestinal systems slows the metabolism and affects
circulation, absorption and metabolism of drugs.
• Drugs can also affect nutritional status of the elderly person
due to some of the side effects e.g. loss of appetite,
nausea, irritable stomach, decreased absorption of
nutrients.

62. Possible side effects of drugs
• Sedatives and hypnotics: confusion, delusion,
hallucinations, falls, agitation, and altered
behavior. They should be given in low doses
• Analgesics e..g salicylates can cause electrolyte
imbalance, bleeding, and nephrotoxicity.
• Tranquilizers: hypotension, cerebral depression
• Central nervous system stimulants: can cause
confusion, paranoia
• Cardiovascular drugs: e.g. digitalis; can cause
dysarrthymias and gastrointestinal and mental
symptoms.

63. NB: when an elderly person is given drugs to
self-medicate, the following should be
explained.
i. Explain the action, side effects and dosage of
each medication
ii. Write out the drugs schedule
iii. Encourage use of standard containers rather
than safety lids.
iv. Destroy old unused medication
v. Periodically review the medication schedule.
vi. Discourage the use of over the counter drugs
without consultation.

65. Counselling the elderly
• Def: counselling is face to face communication in
which one person helps another to make
decisions and act on them.
• Counselling is necessary to prepare the elderly
person in some of the life changes that occur due
to old age.
• Some of the changes are
– Decreased morale,
– Decreased secondary memory,
– Increased introversion,
– Increase need for personal space
– Difficulties in decision making

66. • Developing strategies for coping with those
changes;
–Reviewing one’s life
–Reminiscing about past achievements
–Planning legacies for the future,
–Increasing self concept and self
awareness
–Improving relationship with family and
friends
–Stimulating one’s intellectual ability

67. • Other areas of counseling include
–Building support network
–Repairing family relationship
–Making new friends
–Joining support groups
–Making effort to keep in touch with the
relatives and friends
–Overcoming barriers to good
interpersonal relationship e.g.
bitterness, anger, constant complaints

68. Advantages of counseling
• Clients are able to:
– Modify their behavior to allow them to cope by acquiring
pets or plants to offset their loneliness caused by death of
spouses and friends.
– Organize social network to build a sense of belonging and
have help in times of crisis.
Types of support network
a) Kinship style: network made of relatives
b) Friendship network: made of friends other than relatives
c) Associate network: made up of groups including those
at work or church.
d) Restricted network: limited or non-existent network.
Clients in this kind of network need encouragement to
open up and enlarge their network.

69. Bereavement
• Def: refers to a state of loss resulting from
death of a significant person. It produces
stress and major symptoms in the affected
person.
• The person who has suffered bereavement
may have physical, psychological changes due
to grief.
• Grief is the psychological response to loss of a
loved one.

70. Stages of bereavement
1. Numbness and denial: a person has a sense of
emptiness as if life has stood still. There is also
denial; a feeling that it cannot happen to the
individual.
2. Yearning and pinning: the person is pre-occupied
with images of the dead person. The person feels
that they have seen, talked or heard the dead
person.
3. Despair and depression: stage of acceptance that
the person may get disorganized and some people
may find it difficult to cope with daily task of life and
work. The bereaved person often experiences
despair and depression

71. 4. Reality and organization: the bereaved
person realizes that life must go on without
the dead person. Loss is painful but the
survivor begins to move on with life.

72. Psychological challenges of old
age
Sixty five birthday
• Devaluation
• Negative attitudes
• Age determined
expectation
• Stereotyped and
myths
• Degradation
Retirement
• Loss of income
• Loss of identity/role
• Loss of
status/authority
• Loss of structure/
schedule
• Loss of purpose in life
• Loss of contact

73. Widowhood
• Loss of helper
• Loss of companion
• Loss of sexual
partner
• Emptiness
• Loneliness
• Grief
• Changes in
responsibility
• Dependency on
others
Chronic illness
• Immobility
• Sensory decline
• Medication side effects
• Dependency/vulnerability
• Loss of money
Relocation from family
homestead
• Loss of space
• Changes in
neighborhood
• Move from friends

75. Psychological and physical changes
1. cognition
Def: Cognition is a group of mental processes that includes
attention, memory, producing and understanding language,
solving problems, and making decisions.
• Learning does not necessarily decline with age and is facilitated
when individual set their own pace. Short term memory generally
wanes with age.
• Crystallized intelligence which is based on past experiences
show slight decline with age.
• Fluid intelligence which is biologically mediated declines from
adolescence on.
• Information overload increases (neural noise)
• Need for activity with meaningful outcome increases.
• Cognitive decline may be related to nearness to death (terminal
drop)

76. 2. Self concept/ self esteem: ability to accept age-
related changes becomes important. Need to find
meaningful substitutes for multiple losses increase.
3. Drug therapy: most dynamic effect are frequently
accomplished not through administration of drugs but
through their withdrawal. Age related changes may
greatly affect the rate of absorption, distribution,
metabolism and excretion. Vulnerability to adverse
effects increases with age. Problems related to
intravenous fluid therapy increases.
4. Elimination: disturbances are usually due too diet and
or fluid intake change. Constipation is usually due to
decrease of bulk in diet and decreases in fluid intake.
• Diarrhea is usually due to laxative abuse ( higher in
women than men).

77. • Urinary changes include the following
– Sensitivity of kidneys to sudden acid balance changes
increase.
– Nocturia increase
– Significance of adequate fluid intake increases.
– Lack of urinary control increases social isolation.
– Prostatic enlargement increases frequently.
5. Nutritional state
– Low income has adverse effect on nutrition
– Loneliness may be related to nutritional problems
– Degree of physical activities is a major consideration.
– Condition of the mouth and dentures are important
factors.
– Importance of food rituals surrounding food increases in
old age.

78. 6. Pain: sensitivity changes to pain may occur.
Tolerance to deep pain decreases while tolerance
to subcutaneous pain increases in some instances
death is welcome.
7. Skin: skin grows thin, appears dry, brittle and
fragile. It increases in wrinkles due to loss of
subcutaneous fat. Ability to remain properly
hydrated is lost. It decreases in turgor with
collagen content being increased. Ability to
maintain body temperature decreases. Sexual and
cultural differences are manifested . Sweat glands
function decreases. Pigmentation spots (liver
spots) increases. Number of capillary loops and
blood vessels decreases.

79. 8. Nails: grow slowly. Impairment of peripheral
circulation results in their thickening and
brittleness.

80. 9. Hair: loss occurs but differ between sexes. Loss of
pigmentation causes graying. Decrease in oil makes hair
appearance dull and lifeless. Axillary hair often disappears.
Body and pubic hair decreases.
10. Mouth: there is need for denture due to loss of teeth.
Periodontal disease increases. Secretion reduces. Decline
in number of taste buds results in decreased capacity to
taste.
11. Physical exercise and mobility: muscle size diminishes
and muscle tone and strength decreases. Maximum peak
of strength is between 20 to 30 years of age. Loss may be
secondary to decreased activity. Grip strength is one of the
earliest indication of change. Potassium content declines.
Tendency towards spinal kyphosis (dowagers hump)
develops. Involuntary and painful muscle cramps results
from decreased circulation to the extremities.

81. 12. Bone mass: wide spread decrease occurs. Fractures
occur more frequently in weight bearing areas. Reduction in
height may occur due to intra-vertebral disc changes.
13. Safety: ambiguous environment increases confusion.
Need for environmental clues increases e..g hand rails in
rooms, large size room numbers etc. need for appropriate
designed equipment and furnishing increases. Uneven
walking surfaces can cause falls.
14. Sleep: general pattern frequently changes and period of
sleep becomes shorter. Proportion of REM and non-REM
sleep remain fairly constant until about 60 years of age.
Reduction in slow wave sleep occurs. Deep sleep(stage 4)
is often absent. Concern and anxiety about pattern changes
increases.
15. Time perception: tendency to underestimate time. Need
for structure and adherence to time schedules increases.

82. RETIREMENT
Def: Retirement is the point where a person stops employment
completely. It is one of the major adjustment to be made as an
individual ages. When one looses a work role, for many people it is
one experience of the impact of aging.
• Retirement is difficult especially in a society where worth is
commonly judged by an individual’s productivity. Work is viewed as
a requirement in a productive society.
• Unemployment for whatever reason is viewed negatively.
Occupational identity is responsible for social positions and social
roles.
• Certain characteristics are associated with occupational position e.g.
– Tough construction worker
– Wild exotic dancer
– The fair judge
– The righteous clergy man
– The learned lawyer
– The eccentric artist

83. • People are usually discussed according to their profession e.g. the
nurse who lives down the road.
• All these leads to an individual feeling of loss of identity with
retirement.
• Throughout childhood, adolescence, adulthood, an individual is
guided towards independence and responsible adult role. Nobody is
prepared for old age and how to live.
• Health workers should assist individuals in the preparation of
retirement by:
– Prevention and intervention and maximizing the potential for health and
wellbeing in old age.
– Encouraging aged individuals to establish and practice good health
habits e.g.:
• Eating proper diets
• Avoiding excessive alcohol
• Avoiding drug abuse
• Avoiding tobacco abuse
• Having regular physical examination

84. • Since work is one’s primary interest, activity
and social contact, retirement leaves a void in
a person’s life therefore an aging individual
should be encouraged to develop other
interest unrelated to work.
• Retirement should be facilitated by learning
how to use-appreciated and gain satisfaction
from leisure time and use it as s therapeutic
stress outlet of life stress as one ages.

86. Phases of retirement
1. Remote phase: early in occupational carrier, future retirement is
anticipated but rational preparation is seldom done.
2. Near phase: when reality of retirement is evident, preparation
for leaving one’s job begins as does fantasy regarding the
retirement role.
3. Honeymoon phase: following the retirement event a somewhat
euphoric period begins in which fantasizes from the pre-
retirement period are tested. Retirees attempt to do everything
they never had time for simultaneously. A variety of factors
interferes e.g., health; limits this leading to the development of a
staby lifestyle.
4. Disenchantment phase: as life begins to stabilize a letdown,
sometimes a depression is experienced. The more unrealistic
the pre-retirement fantasy, the greater the degree of
disenchantment.

87. 5. Re-orientation phase: realistic choices and
alternative sources of satisfaction are
considered. The disenchantment with the new
retirement routine can be replaced by
developing a lifestyle that provides some
satisfaction.
6. Stability phase: an understanding of the
retirement role is achieved and provides a
framework for concern; involvement and action
in the elderly person’s life. Some enter this
phase directly after honeymoon phase and
some never reach it at all.

88. 7. Termination phase: the retirement role is lost
as a result of either the resumption of work role
or dependency due to illness or disability

89. Role of a nurse in retirement
1. Counselling: preparation of retire and realities of retirement.
Helping the retiree place their new found freedom into
proper perspectives.
2. Being supportive and helping the retiree find new identity
sources.
3. Facilitating in re-orientation process
4. Tactful management of dependency, when it occurs due to
evaluation of their own attitudes towards retirement or as
an essential part of their role towards retirement.
5. Do they see retirement as period of freedom, opportunity,
growth or one of loneliness, dependency and
meaninglessness.
6. Are nurses intelligently planning for their own retirement
with realities.

90. Counseling the elderly
• The older person needs to be counselled on:
– Family support
– Sensitivity of the community to the needs of the elderly
– Preparation for retire
• Counselling is necessary to prepare the elderly person
in some life changes that occur due to old age like
– Decreased morale
– Decreased secondary memory
– Increased introversion
– Personal space needed
– Heightened cautiousness in trying new things or making
important decisions.
– Developing potential strategies to cope with these changes

91. Strategies
1. Reviewing one’s life
2. Reminiscing about past events
3. Planning legacies for the future
4. Increasing self awareness to improve relationship with
family and friends.
5. Stimulating one’s intellect exercising and meditation.
6. Building support network
7. Repairing family relationship
8. Making new friends
9. Joining support groups
10.Making effort to keep in touch with relatives and old
friends.

92. • Barriers to good relationship formation include;
– Bitterness
– Anger
– Constant complaining
• Counselling helps the person to modify their behavior to
allow them to cope.
• Acquiring a pet or plant may offset loneliness caused by
loss of relatives.
• Social network allows the elderly person to have a sense
of belonging
• Disappearance of regular contacts makes the elderly
person to feel constriction of life space with decreased in
self worthy, apathy and withdrawal.
• Social network should be wide so that they can meet a
person’s needs during crisis and provide regular positive
feedback.

93. 4 basic networks
1. Kinship style: network primarily made of
relatives.
2. Friendship style: network made of friends
than relatives.
3. The associate style: network largely related
to groups including those associated with
work.
4. Restricted style: network limited or non
existence (clients with this style may need
encouragement to improve networking).

94. COGNITION AND PERCEPTION IN OLD
AGE
• Cognition: deals with the way people gain
information from the environment and the way
they interpret and use information.
• Perception: includes collection, interpretation
and recognition of stimuli including pain.
• Cognition: intelligence, memory, language and
decision making
• Cognition and perception is connected in the
CNS with special senses of vision, hearing, touch
,smell and taste.

95. Types of intelligence
1. Fluid intelligence (young people): ability to
perform tasks or make judgment based on
unfamiliar stimuli (known as thinking on your
feet).
2. Crystallized intelligence (old people) : ability
to perform tasks or make judgment based on
knowledge and experience acquired through
life time (wisdom).

96. Perception and cognition and aging
• Aged person experiences sensory changes
interfering with collection of information. Many aged
persons are considered confused or are suffering
from altered sensory perception.
• Elderly people who do not see or hear well may walk
out into traffic or make mistakes about direction; not
due to failure of proper sensory information.
• Intelligence does not automatically decrease with
aging nor does the ability to learn.
• Elderly people may appear to be less intelligent due
to tendency to be slower and more cautious in their
response.

97. • Lack of formal education may also cause the
elderly person to appear less intelligent. They
may lack polish in speech or have less
vocabulary.

98. • The speed at which information is processed and
recalled does change with age. Forgetfulness or
memory loss is common with aging; at 75 years
as much as 30% of memory is lost.
• Most elderly can compensate for gaps in memory
by using experiences gathered over a lifetime.
• Ability to acquire new information also appears to
decrease with age. This could be more of a lack
of desire to learn than inability to acquire and
retain information. Once information is learned
the alert elderly person is able to recall it as a
younger person.

99. Taking history of an elderly person and
physical examination
• Ensure the client’s comfort, empty bladder, lenses and denture
should be in situ.
• The room should be well lit with no background noise.
• Privacy should be ensured and the client asked if he wants to be
interviewed alone or with relatives.
• If client is mentally impaired history should be verified by
significant others.
• History includes:
– Reasons for contact
– Demographic data
– Source and reliability of the history
– Present health status, past health status (past medical, obstetric or
psychiatric history)
– Family history
– Personal and social history

100. Physical examination
• General survey; height, weight, tissue distribution and bony structure, gait.
• Loss of height: 65 – 74 yrs…….1.5 inches
75 – 94 yrs…….3 inches
• Weight: males loose weight at 55 years,
women gain weight at 50 years;
weight is lost in mid 70’s.
• Fat distribution change from extremities to the middle.
• Skin: thinner, wrinkling, hyperpigmentation, dermatitis, fungal infections,
bacterial infections and malignancy of the skin. The skin is dry and turgor
is lost.
• Nails: brittle
• Hair: grey or white; loss of hair
• Head and neck
• Thorax and lungs
• CVS- BP, heart sounds, blood vessels, blood

101. • Breasts for female: size, shape, atrophy masses; male-
gynecomastia
• Abdomen: it is easier to palpate organs due to loss of fibro-
connective tissue and muscle wasting. Liver and kidneys
decrease in size. Palpate the abdomen for masses. Bladder if
distended may be palpated. Rectal exam can be done to
confirm findings.
• Genito-urinary exam:
• Females: vulva thin due to loss of fatty tissue and skin atrophy
– Check for irritation of the skin, ulceration erythema and swelling.
– Urethra is examined for swelling , inflammation or prolapse.
– Pelvic exam is also performed to check the tract for abnormalities,
irritation and infections
– There is weakening of uterine support and uterus may prolapse.
– There is increased incidence of cervical and endocervical cancer in
older people.

102. • Males: pubic hair is sparse and gray.
– Penis decreases in size with progressive sclerosis of
arteries and veins.
– Testis are decreased in size and are less firm on palpation.
– Prostate gland is palpated per rectum and must be checked
for hypertrophy or cancer of the prostate.
• Musculoskeletal system
– Check muscles of lower and upper extremities. Note muscle
wasting and replacement with fat.
– Degenerative changes in joints leading to inactivity
– Progressive muscle weakness which should be noted
– Observe posture
– Spine is observed for alignment and curvature and flexibility
– Kyphosis may be present
– Check for signs and symptoms of osteoarthritis

103. • Neurological system
– Motor function: assessed by observing muscle bulk,
tone, strength, posture, gait, balance or co-ordination.
– Cranial nerve: allow more time since clients reaction
time decreases with time.
– Reflexes: are diminished, sluggish or absent.
• Sensory function
– Clients require adequate time to respond to direction
– In presence of mental status changes, it is difficult to
assess.
– There is diminished tactile sensation.
– There is diminished deep pain sensation
– Perception of temperature is diminished

104. Investigations
1. Hematological: testing should be compared with those of
normal young adults. RBCs, WBCs, serum chemistry,
serum enzymes
2. Urine testing
3. Sputum testing
4. Stool test
5. Mental status assessment; focus on
 Cognitive- memory, reasoning and intelligence
 Emotional adaptation- interpersonal relationship, social
relationship, social support.
6. Sexual functioning
7. Economic resources
8. Functional status especially the capacity to perform
activities of daily living.

105. Activities of daily living
• Eating
• Dressing
• Bathing
• Toileting
• Achievement of urinary continence
• Achievement of bowel continence
• Ambulating, using a wheel chair
• Transferring from bed to chair; in and out of
bath; in and out of the cars
• Communicating

106. Elder abuse
This occurs due to:
• Number of very old including men and women, very frail or
impaired.
• Children called upon to care for the parents with lack of skills,
resources which may lead to abuse and neglect.
• Fewer adult children available to take care of parents due to
population mobility, stress, burden to those caregivers who
are available; leading to increased to abuse and negligence.
• Reporting system is increased
Types of abuse
• Physical abuse; battering
• Psychological abuse
• Misuse of property
• Violation of rights

107. • Types of abused elderly
– Women of advanced age; with few social contacts
and with at least one physical or mental impairment
that limit their activities of daily living.
– The person lives alone or with the abuse
– The person depends on the abuser for care.
• Characteristics of elder abusers
– Those with financial difficulties
– Those with history of violence
– Those sharing a household.
– Those with intra-family conflicts
• Contributing factors: cultural norms e.g. ageism,
sexism, stereotyping, people with disabilities.

108. Victims of abuse
• Victims of physical abuse—those who are young and married.
• Victims of neglect are older and single.
• Victims of self neglect; male, older living alone and are isolated
from family, have dementia, are mentally ill, have substance
abuse
Causes of elder abuse
 Ageism
 Retaliation
 Caregivers stress
 Caregivers unemployment
 Environmental conditions
 Increased life expectancy
 Resentment of dependency
 Lack of community resources

109.  Lack of close family ties
 Violence as a way of life
 A history of personal and mental problems
 A history of alcohol and drug abuse
Risk factors
1. Invisibility: lack of contact of older people with
communication. Unwillingness of older people to admit that
they are being neglected/abused due to desire to protect the
abuser or fear of reprisal or negative feelings about aging.
2. Vulnerability: due to:
– Inability to meet their own physiological needs
– Inability to manage their finances
– Danger to self and others due to mental impairment
– Lack of close relatives or other willing to provide adequate and
appropriate assistance.
– need for protective services

110. Factors that contribute to vulnerability are:
1. Personal characteristics- isolation
2. Situational characteristics e.g. poverty or
pathological caregivers
3. Environmental factors e.g. deteriorated
housing, crime ridden neighborhood
4. Social factors e.g. learned helplessness,
giving up in violent sub-cultures.
5. Psychosocial factors e.g. mental disability,
depression, self neglect, lack of support
system.

111. • Care give factors that contribute to
vulnerability include:
–Perception of social isolation
–Decline in health
–Dependence
–Co-residence
–External control
–Poor interpersonal relationship with
dependent elder

112. Functional consequences
1. Type of abuse
 Physical: hitting, shoving, denying food or medication
 Psychological: threats, calling names, failure to provide proper
supervision and social interaction.
2. Exploitation: forcing elderly to change their will or deed
3. Violation of rights: denying privacy and visitors,
abandonment and sexual assault.
Responsibility of KRCHN
4. Detect and follow up cases of elder abused in the community
5. Arranging alternate care for older person
6. Organising legal intervention when necessary
7. Attending to physical health needs of the neglected or
elderly person

113. • Tasks of old people by havighurt;
1. Adjustment to decreasing physical strength
and declining health
2. Adjust to retirement and fixed income
3. Adjust to death of spouse or companion
4. Establish social relationship with people of
the same age and with younger person
5. Establish appropriate living arrangement
6. Make arrangement for care of needed
7. Accept one’s mortality

114. Choices in later adulthood
Loss of spouse and other family members and friends
Changing (probably deteriorating) body function and
physical abilities
Loss of sexuality or person to relate sexually
Retirement and great amount of leisure, time and
feelings of self-worth.
Income adjustment and plans for future apartment,
warm or cold climate e.t.c
Getting along with own children; young and older
grandchildren
Dealing with own death

115. Other characteristics of old
people
1. Desire to leave a legacy e.g. children, money,
works of art, writing, personal possessions.
2. The elder role; they enjoy sharing
accumulated experiences, wisdom and
knowledge with the young.
3. Attachment to familiar objects
4. Changes in the sense of time
5. Sense of life cycle.
6. Creativity, curiosity and surprise.

116. GRIEF
Def: is a subjective state of emotional , physical and social
response to a valued entity.
Types
1. Anticipatory grief: Grief that begins before (in anticipation of)
the loss, such as the initiation of divorce proceedings or when a
loved one is diagnosed with a terminal illness.
2. Anniversary reactions: Grief responses that occur following
reminders of the loss, such as on anniversaries, holidays or
other special days throughout the year. These can last for days
or weeks, and are not necessarily a setback in the grieving
process.
3. Complicated grief (also called Traumatic Grief): Occurs when
grief becomes chronic, disabling and more intense. This is often
seen as a progression of grief into major depression, with some
features of post-traumatic stress disorder, such as nightmares
and flashbacks.

117. Types of loss
• Real loss e.g. of a loved one, property or
relationship which can be shared by others.
• Perceived loss: that is felt by the individual alone
and not shared by others e.g. loss of feminity
following a major operation e.g. mastectomy or
hysterectomy
NB: Any situation which cause change can be
identified as loss. Failure either real or perceived
can be viewed as loss. Loss or anticipated loss
can trigger a grief response. The period of grief is
known as mourning which is a normal response
characterized by sadness, guilt, anger,
helplessness and despair.

118. STAGES OF GRIEF
1. SHOCK & DENIAL-
The person reacts to learning of the loss with numbed
disbelief. He deny the reality of the loss at some level, in
order to avoid the pain. Shock provides emotional protection
from being overwhelmed all at once. This may last for weeks.
2. PAIN & GUILT-
As the shock wears off, it is replaced with the suffering of
unbelievable pain. Although excruciating and almost
unbearable, it is important that you experience the pain fully,
and not hide it, avoid it or escape from it with alcohol or
drugs. He/she may have guilty feelings or remorse over
things he/she did or didn't do with your loved one. Life feels
chaotic and scary during this phase.

119. 3. ANGER & BARGAINING-
Frustration gives way to anger, and one may lash out and lay
unwarranted blame for the death on someone else. This is a time
for the release of bottled up emotion.
• One may rail against fate, questioning "Why me?“ one may also try
to bargain in vain with the powers that be for a way out of his/her
despair ("I will never drink again if you just bring him back").
4. "DEPRESSION", REFLECTION, LONELINESS-
Just when one’s friends may think he/she should be getting on with
life, a long period of sad reflection will likely overtake him/her. This
is a normal stage of grief and one should not be "talked out of it" by
well-meaning outsiders. Encouragement from others is not helpful
during this stage of grieving.
• During this time, one finally realizes the true magnitude of his/her
loss, and it depresses him/her. One may isolate self on purpose,
reflect on things he/she did with his/her lost one, and focus on
memories of the past. One may sense feelings of emptiness or
despair.

120. 5. THE UPWARD TURN-
As one starts to adjust to life without his/her dear one, his/her
life becomes a little calmer and more organized. One’s
physical symptoms lessen, & "depression" begins to lift
slightly.
6. RECONSTRUCTION & WORKING THROUGH-
As one becomes more functional, his/her mind starts working
again, and you will find yourself seeking realistic solutions to
problems posed by life without your loved one. You will start
to work on practical and financial problems and reconstructing
yourself and your life without him or her.
7. ACCEPTANCE & HOPE-
One learns to accept and deal with the reality of his/her
situation. Acceptance does not necessarily mean instant
happiness. Given the pain and turmoil one has experienced,
one can never return to the carefree, untroubled self that
existed before this tragedy.

121. Kubler Ross model
• The stages, popularly known by the acronym DABDA, include:
1. Denial — "I feel fine."; "This can't be happening, not to me."
Denial is usually only a temporary defense for the individual. This
feeling is generally replaced with heightened awareness of
possessions and individuals that will be left behind after death.
Denial can be conscious or unconscious refusal to accept facts,
information, or the reality of the situation.
2. Anger — "Why me? It's not fair!"; "How can this happen to me?";
'"Who is to blame?"
Once in the second stage, the individual recognizes that denial
cannot continue. Because of anger, the person is very difficult to
care for due to misplaced feelings of rage and envy. Anger can
manifest itself in different ways. People can be angry with
themselves, or with others, and especially those who are close to
them. It is important to remain detached and nonjudgmental when
dealing with a person experiencing anger from grief.

122. 3. Bargaining — "I'll do anything for a few more years."; "I will
give my life savings if..."
The third stage involves the hope that the individual can
somehow postpone or delay death. Usually, the negotiation for
an extended life is made with a higher power in exchange for a
reformed lifestyle. Psychologically, the individual is saying, "I
understand I will die, but if I could just do something to buy
more time..." People facing less serious trauma can bargain or
seek to negotiate a compromise. For example "Can we still be
friends?.." when facing a break-up. Bargaining rarely provides a
sustainable solution, especially if it's a matter of life or death.
4. Depression — "I'm so sad, why bother with anything?"; "I'm
going to die soon so what's the point?"; "I miss my loved one,
why go on?"
During the fourth stage, the dying person begins to understand
the certainty of death. Because of this, the individual may
become silent, refuse visitors and spend much of the time
crying and grieving.

123. • This process allows the dying person to disconnect from
things of love and affection. Don’t attempt to cheer up an
individual who is in this stage. It is an important time for
grieving that must be processed. Depression could be
referred to as the dress rehearsal for the 'aftermath'. It is a
kind of acceptance with emotional attachment. It's natural to
feel sadness, regret, fear, and uncertainty when going through
this stage. Feeling those emotions shows that the person has
begun to accept the situation.
5. Acceptance — "It's going to be okay."; "I can't fight it, I may
as well prepare for it."
In this last stage, individuals begin to come to terms with their
mortality, or that of a loved one, or other tragic event. This
stage varies according to the person's situation. People dying
can enter this stage a long time before the people they leave
behind, who must pass through their own individual stages of
dealing with the grief.

124. Length of the grief process
• Stages of grief allow the bereaved person or elderly
approach resolution of mourning.
• Each stage of grief present tasks to be overcome
through painful experimental processes.
• Grief is complete when a person can remember
comfortably and realistically both the pleasures and
disappointment of the lost person or object.
• Length of grief is individualistic and can last a
number of years without being maladaptive.
• Acute phase lasts 6 to 8 weeks but its longer in
older adults where it takes 6 months to 1 year.

125. Factors that influence outcomes of grief
1. The importance of the lost object or person as a source of
support
2. The degree of dependency on relation with lost object or
person.
3. The number and nature of other meaningful relationship the
mourner has.
4. The degree of ambivalence felt towards the lost person or
object.
5. The number and nature of previous grief experiences e.g.
grief which can be cumulative especially when the previous
grief has not been resolved.
6. The age of the lost person e.g. child, adult or elderly person.
7. Health of the mourner at the time of loss. Status of physical,
psychological condition and coping capacity for stress.
8. The degree of preparation for the loss.

126. 1. Anticipatory grief
• It is the initiation and actual process of grieving that takes
place when anticipating a significant loss before it takes
place.
• Stages of grieving are similar to those of normal loss with a
difference that conventional grief tends to reduce in intensity
as time passes.
• Anticipatory grief increases in intensity as expected loss
becomes more imminent.
Disadvantages
1. If family members complete the process of grieving then
attachment from the dying person occurs prematurely.
2. The person experiences loneliness, isolation as well as
psychological pain of imminent death without family support.
3. There may be problem of re-establishing prior relationship
after grieving if death does not occur.

127. Maladaptive response to loss
• Delayed or inhibited grief: absence of grief
when it ordinarily would be expected. It is
caused by:-
– Cultural influences
– Danger; the person is fixed in denial stage
• Grief may be triggered later by another
unrelated event or another loss resulting in
over-reaction. It occurs due to :-
– Ambivalent feelings
– Outside pressure to resume normal function
– Perceived lack of internal and external sources to
cope with profound loss.

128. 2. Prolonged grief
• Grief is considered prolonged if activities of normal
living are not resumed after a period of 4 to 6 weeks.
• If grief is associated with self-blame; difficulties
accepting loss, sudden untimely loss, history of
dependence on the dead person.
Signs and symptoms
1. Development of physical symptoms experienced by
the dead person
2. Progressive social withdrawal
3. Poor interpersonal relationships with friends and
relatives
4. Participation in activities detrimental to one’s social
or economic existence.

129. 3. Exaggerated grief
• Signs and symptoms of normal grieving
process are exaggerated.
• Feeling of sadness, helplessness,
hopelessness, anger and guilt are
accompanied by other somatic complaints.
• This leads to overwhelming behavior without
progression toward completion of the grieving
process.
• Individual is fixed in anger stage and blames
others or self for the loss which leads to
depression.

130. Stages of death by Kubler Ross 1969
1. Denial and isolation: it is very difficult for any individual to
face the fact that death is to be faced soon. The most common
reaction is to isolate oneself until defences are achieved.
• Denial permits hope to exist but most patients are ready to
accept the fact that they are dying but families continue to
express denial.
• Denial delay, communication of concerns with the patient
stopping denial and isolation by thinking about unfinished
business e.g. personal affairs, finances, arrangement for
spouse, children and others.
2. Anger: the person experiences anger with the person asking
the question; why me? The patient is difficult to nurse as
nothing seems to please him or her. The person wants to
express their outrage and helplessness. After expressing their
anger they move on.

131. 3. Bargaining: third phase of dying when the
person attempts to negotiate and trade. It usually
involves a deal with God; the physician or the
nurse. E.g. If I can live long enough to attend my
son’s wedding I will be ready to die. If possible
patients should be granted their request.
4. Depression: the patient is now aware that death
is inevitable. Defense mechanism are no longer
effective. Sadness and anguish are felt and
expressed.
• The patient may organize to gain support from
loved one’s and nurses.
• The resolution leads to final stage.

132. 5. Acceptance: it’s a time of relative peace. The patient wants to review
the past and think about the unknown future. Patient may not talk a lot
about but he/she wants other people nearby. With pain relieve the
person accepts death and wants to be comforted by having significant
others nearby.
Nursing intervention
1. To give maximum help to the dying by examining the nurse’s own
feeling about death.
2. Patient is an individual and should be treated with respect and dignity
regardless of background or condition.
3. Social values may affect reaction to the dying person e.g. age,
attractiveness, socio-economic status, former accomplishment. These
may affect whether the person is cared for or abandoned while dying.
4. Nurses usually become the most important link with life for the dying
person.
5. The nurse provides physical comfort and emotional support. It is an
emotional stress to the nurse assigned to people who are dying and
these need to share their feelings and reactions with others to obtain
support.

133. Bill of rights for a dying person
1. I have a right to be treated as a living human being until I die
2. I have a right to maintain a sense of hopefulness, however
changing its focus may be.
3. I have the right to be cared for by those who can maintain a
sense of hopefulness, however changing this may be.
4. I have a right to express my feelings and emotions and my
approaching death in my own way.
5. I have a right to participate in decision concerning my care.
6. I have a right to expect continuing medical and nursing
attention even though “cure” goals must be changed to
comfort goals.
7. I have a right not to die alone.
8. I have a right to be free from pain.
9. I have a right to have my questions answered honestly.

134. 10. I have a right not to be deceived
11. I have a right to help from and for my family in accepting my
death.
12. I have the right to die in peace and with dignity
13. I have the right to retain my individuality and not to be
judged by my decision, which may be contrary to the
believes of others.
14. I have the right to discuss and enlarge my religious and
spiritual experience, regardless of what they mean to others.
15. I have the right to expect that the sanctity of the human
body will be respected after death.
16. I have the right to be cared for by caring, sensitive and
knowledgeable people who will attempt to understand my
needs and will be able to gain some satisfaction in helping
me face my death.

135. PALLIATIVE CARE
Def: comprehensive person and family centered care
when disease is not responsive to treatment.
• Hospice care: care concerned with end of life
focussing on realistic social, emotional, spiritual
and financial preparation for death.
• It addresses the whole person including physical,
social and spiritual aspect in life threatening illness.
• Hospice care can be defined as provided to
terminally ill person’s and their families in the last 6
months of the patient's life. Most patients are
referred for hospice care when its too late in their
illnesses.

136. Reasons for late referral
1. Values and attitudes of health care providers
2. Inadequate dissemination of existing knowledge
about pain and symptom management.
3. Health care providers difficulties in effectively
communicating with the terminally ill person.
4. Insufficient attention to palliative care concept in
health care provider’s education and training.
5. Confusion about eligibility criteria for hospice
services.

137. 1. Palliative care in hospital setting:
• 50% of all deaths occur in the hospital set-up.
In hospital set up:-
– Many patients received unwanted care at the end of
life.
– Clinicians are not aware of the patient’s preference
for life sustaining treatment even when preference
were documented in the clinical records.
– Pain is often poorly controlled at the end of life.
– Efforts to enhance communication are ineffective
2. Palliative care in long-term care facilities:
– These are homes for the aged where most of the
residents die. Palliative care can be offered there.

138. 3. Hospice care:
• Hospice care is not a home but a concept of care in
which the end of life is viewed as a developmental
care. Hospice is derived from the word
“hospes”….meaning “hosts”.
• Historically hospice is referred to as shelter or way
station for weary travels on a pilgrimage. Hospice care
has become an alternative to depersonalize death in
institutions.
• Hospice care began as a response in gaps in care e.g.
– Between treating the disease and treating the person
– Between technological research and psychological support
– Between the general denial of the facts of death in the
society and acceptance of death by those who face it.

139. Principles of hospice care
1. Death must be accepted
2. The patient’s total care is best managed by an
interdisciplinary team whose members
communicate regularly with each other.
3. Pain and other symptoms of terminal illness
must be managed.
4. The patient and family should be viewed as a
single unit of care.
5. Home care of the dying is necessary
6. Bereavement care must be provided to family.
7. Research and education should be ongoing.

140. • Hospice movement is based on a belief that meaningful living is
achievable during terminal illness. Its best supported in the
home free from technology intervention to prolong physiologic
dying.
• In hospice set up the patient and his family make up a unit of
care. The goals is to enable the patient to remain at home
surrounded by the people and objects that have been important
to him/her throughout life.
• Hospice does not seek to hasten death or encourage the
prolongation of life through artificial means.
• The care is based on competent patients full or open awareness
of dying embracing realism about death.
• It helps the patient’s family to understand the dying process so
that they can live each moment as fully as possible.
• Although most care is given in patient’s home, some
programmes have developed in-patient facilities or residences
where terminally ill person’s have no support.

141. Eligibility criteria
a) Patient must have progressive irreversible illness
b) Limited life expectancy
c) Client must have opted for palliative care
d) It does not only serve cancer patients but any patient
with life-limiting illness.
e) Presence of a family member or other caregiver
continuously in the home when the patient is no
longer able to safely care for him/herself.
Types of care offered
– routine home care
– Continuous care
– General in-patient care
– In-patient respite care

142. Nursing care of terminally ill patients
1. Psychosocial issue
– Education about illnesses and patient’s life with the illness
– Value clarification
– Treatment decision making
– End of life closure
• Nurses should try and understand the illness from the
patient's point of view.
• An honest discussion about death should be held giving
the patient information on illness, end of life choices, open
discussion about death.
• At the same time the nurses should be culturally aware
and sensitive in their approaches to communication about
death to patient and relatives and how much information
they can handle.

143. • Patient’s should be allowed to communicate their
wishes about the end of their life e.g. about the use of
or non-use of medical treatment; authorizing other
people to make decisions for them.
2. Communication
• General guidelines
– Deliver and interpret the technical information necessary for
making decisions without hiding behind medical terminology
– Realize that the best time for the patient to talk may be when
it is least convenient for you.
– Being fully present during any opportunity for communication
is often the most helpful form of communication.
– Allow the patient and family to set the agenda regarding the
depth of the conversation.

144. Key to effective listening
1. Resist the impulse to fill the empty space in
communication with a talk.
2. Allow the patient and family sufficient time to reflect
and respond after asking a question.
3. Prompt gently, do you need more time to think about
this?
4. Avoid distraction/interruptions
5. Avoid impulse to give advice
6. Avoid canned response e.g. I know just how you feel.
7. Ask questions
8. Assess understanding; your own and the patient by
restating, summarizing and reviewing.

145. 9. Spiritual care
Mnemonic SPIRIT
S- spiritual belief system
P- person spirituality
I- integration and involvement with others in a spiritual community
R- ritualized practices and restriction
I- implication of medical care
T – terminal events planning
10. Hope
11. Realistic initial assessment of the threat
12. Envisioning alternative and setting goals
13. Bracing for negative outcomes
14. Realistic assessment of resources
15. Solicitation of mutually supportive relationship.
16. Continuous evaluation of signs reinforcing the goals.
17. Determination to endure

146. Nursing intervention to improve or
support hope
1. Listening attentively
2. Encouraging sharing of feelings
3. Providing accurate information
4. Encouraging and supporting the patient’s control over his or
her circumstances, choices and environment whenever
possible.
5. Assisting patients to explore ways of finding meaning in
their lives.
6. Encouraging realistic goals
7. Facilitating effective communication within families
8. Making referrals for psychological and spiritual counseling
9. Assisting with development of supports in the home or
community when none exist

147. Managing physiologic response to terminal
illness
• Common symptoms of the end of life illness
• Symptoms caused by the disease directly or indirectly
• Symptoms caused by treatment for the disease
• Symptoms caused by co-existing disorders e.g disease or pain.
Assessing symptoms associated with terminal illness
• How is this symptom affecting the patient’s life?
• What is the meaning of the symptoms to the patients and to the family?
• How does the symptom affect the physical functioning, mobility, comfort,
sleep, nutritional status, elimination, activity level and relationship with
others?
• What makes the symptoms better?
• What makes it worse?
• Is it worse at any particular time of the day?
• What are the patient’s expectation and goals for managing the symptoms?
• How is the patient coping with the symptoms?
• What is the economic effect of the symptoms and its management.

148. 1. Pain
• Pain is usually many of the end of life illnesses e.g. cancer.
• Poor management of pain affects psychological, emotional,
social and financial well being of the patient.
• Patients on analgesic for pain should continue receiving
those medications and inability to complain should not be
mistaken for absence of pain. If patient is unable to
swallow oral analgesic, drugs can be administered per
rectal or sublingually.
• Drugs to combat constipation should also be administered
with opioid medication.
• Relatives should be taught how to continue offering
comfort at home.
• Drug duration should be altered with pain increase 3 to 4
hours continuously.

149. 2. Dyspnoea
• Where possible treatment, of the underlying cause e.g.
anemia
Assessment of dyspnoea
Symptoms intensity, distress and interference with activities.
Auscultation of lung sounds
Assessment of fluid balance
Measurement of dependent oedema (circumference of
lower extremities)
Measurement of abdominal girth
Temperature
Skin color
Sputum quantity and character
cough

150. Nutrition and hydration at the end of life
1. Anorexia
• Anorexia and cachexia are very common symptoms of any
serious illness. This is usually characterized by:
– disturbance in carbohydrates, proteins, and fat
metabolism
– Dysfunction of the endocrine system
– Anemia; can be exacerbated by situation such as
inability to have meals with the progression of the
disease
Management
• Use of pharmacological agents to stimulate appetite e.g.
dexamethasone, megestrol acetate, dronabinol. They give
temporary weight gain. They should be tapered after 4 to 8
weeks if no response.

151. 2. Cachexia
Def: Severe muscle wasting and weight loss associated with illness.
Tips to promote nutrition for terminal illness patients.
 Offer small portions of favorite food
 Do not be overly concerned about a balanced diet.
 Cool foods may be better tolerated than hot foods.
 Offer cheese, eggs, peanut butter, fish, chicken (meat may taste
bitter and unpleasant)
 Add milkshakes, milk
 Place nutritious food at the bedside, fruits and juices
 Schedule for meals when relatives are around.
 Avoid argument at meal times
 Help on oral care
 Allow patient to refuse food and fluids
 Treatment of pain and other symptoms

152. THE END
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