N114 – CARE OF THE ELDERLY

GERIATRICS  Confidence increases with less

 The care of the frail older person, reliance on the approval of others.
or the older person with multiple  Self-understanding and acceptance
chronic conditions or increase.
comorbidities in an acute care
hospitals, rehabilitation centers, LONGEVITY & THE SEX
long-term care facilities, assisted DIFFERENTIAL
living residences, home and  Prior to 1950, the male population
community settings, ambulatory outnumbered the female
clinics, and a variety of other population.
settings.  In 1950, this trend reversed.
 The core values and principles of  Women comprise the majority of
GERIATRIC & the older population (55%) in all
GERONTOLOGICAL nursing nations, & the majority of these
include; women (58%) live in developing
- Health promotion countries.
- Disease prevention &  Older women face different
- Treatment of disease, with circumstances than men as they
emphasis on evidenced based age. They are more likely to be
best practices & current clinical widowed, to live alone, to be less
practice guidelines. educated, & to have fewer years of
A well-educated gerontological nurse is a labor experience, resulting in
vital member of the healthcare team & will poverty.
bring improved health outcomes to older
patients & their families by providing LIFE EXPECTANCY
appropriate skilled nursing care &
 In most nations male life
improving quality of life.
expectancy has not improved as
GERONTOLOGY
much as female, & the differences
 Is a new science that deals with the
between male & female longevity
study aging. It involves all aspects
have widened over time.
of an older person’s life, including
 Ò Some demographers predict that
physical, social, psychological, &
the gender gap will occur in
spiritual functions.
developing countries as well over
 Its focus is to study, diagnose, & the next several years as women
treat disease. “catch up” to men in terms of
 And lately the study has moved educational & economic
beyond the disease focus to the attainment.
improvement of health holistically,  Gender differences in life
including physical, mental, expectancy may be explained by
emotional, & spiritual well-being. the complex interaction between
 the goals of the nurse who provide biological, social, & behavioral
healthcare to older people is not factors.
only to live them longer but also to  Greater male exposure to risk
help them live better, factors among male such as
tobacco, alcohol, & occupational
BENEFITS OF HEALTHY AGING hazards might negatively affect
 Creativity and confidence are male life expectancy.
enhanced.
 Coping ability increases.
 Gratitude and appreciation deepen.
 LIFE AFTER 65 3 MAJOR MISCONCEPTION ABOUT
 Women who reach the age of 65 AGING & HEALTH
can expect to live another 19 years.  Disease in old age is normal.
 Men after 65 can expect to live  Older adults have no future &
another 16 years. therefore health promotion efforts
 This increase in life expectancy are wasted.
is attributed to improved  Damage to health from poor diet
healthcare, increased use of and inactivity is irreversible.
preventive services, & healthier
lifestyles. TOP 10 CAUSES OF DEATH IN THE
 Expert disagree as to whether this U.S.
trend in life expectancy can 1. Diseases of the heart
continue without major treatment 2. Cancer
advances or even cures in heart 3. Stroke
dse. & cancer, the major causes of 4. COPD
elderly deaths. 5. Unintentional injury
6. Diabetes Mellitus
RECOMMENDED PREVENTIVE 7. Influenza & Pneumonia
SERVICES FOR OLDER PEOPLE TO STAY 8. Alzheimer’s disease
HEALTHY 9. Nephritis & Nephrosis
 Screenings for breast, cervical, 10. All other causes
vaginal, colorectal, & prostate MOST COMMON CAUSES OF
cancer. DISABILITY IN THE U.S.
 Fecal occult blood testing (once 1. Arthritis & Rheumatism
yearly) 2. Back or Spine problems
 Flexible sigmoidoscopy (once 3. Heart trouble/ hardening of the
every 4 years) arteries
 Colonoscopy (once every 2 years 4. Lung or respiratory problems
for those at high risk) 5. Deafness or Hearing problems
 Barium enema 6. Limb/ Extremity stiffness
 Mammograms (routine screenings 7. Mental or Emotional problems
once yearly) 8. Diabetes Mellitus
 Pap smears & pelvic examination 9. Blindness or Vision problems
(once yearly) 10. Stroke
 Prostate-specific antigen (PSA) test
(once yearly) PROVEN EFFECTIVE STRATEGIES IN
 Bone mass screening- once yearly PROMOTING HEALTH AMONG
for those at risk. OLDER ADULTS
 Diabetes monitoring- glucose  HEALTHY LIFESTYLE – research
monitors, test strips, lancets, & has shown healthy life styles are
self-management training for those more influential than genetic
with diabetes. factors.
 Flu, pneumonia, & hepatitis B  EARLY DETECTION OF
vaccinations- annual flu vaccine, DISEASE- screening to early detect
pneumonia vaccine at the chronic diseases when they most
physician’s discretion, & hepatitis treatable can save many lives.
B vaccine for those at medium to (cancer)
high risk for hepatitis.
 IMMUNIZATIONS- most of people
aged 65 & above dies due to
 influenza & invasive increased sensitivity to glare,
pneumococcal dse. difficulty seeing moving objects.
 INJURY PREVENTION- falls are Adapting to light changes &
most common cause of injury driving @ night is difficult.
among older.  HEARING- difficult to hear higher
 SELF-MGT. TECHNIQUES- frequencies with aging. Difficulty
programs to teach older adults self- distinguishing vowels &
mgt. techniques can reduce pain & understanding speech esp. in
costs of chronic dse. situations with high levels of
THEORIES OF AGING background noise. Hearing declines
 Study of aging continues to grow more quickly in men than women.
& evolve, & new insights are  PERSONALITY- changes rarely
uncovered daily as scientists make change to healthy older person.
progress. With health problems & depression
 Understanding aging began as a leads to social isolation.
pursuit of one all-encompassing BIOLOGICAL AGING THEORIES
theory, it evolved to the knowledge PROGRAMMED THEORIES
that multiple processes can affect -hypothesized that the body’s genetic
how human age. codes contain instructions for the
 These processes combine & regulation of cellular reproduction &
interact on many levels, & death.
individual cells, proteins, tissues, & 1. Programmed longevity- aging
organ systems are all involved. is the result of the sequential
 Gerontologists prefer to use the switching on & off of certain
term senescene when referring to genes, with senescene defined as
progressive deterioration of body the point in time when age-
systems that can increase risk of associated functional deficit are
mortality as an individual gets manifested.
older. 2. Endocrine Theory- biological
clocks act through hormones to
NORMAL AGING CHANGES control pace of aging. Through the
OBSERVED use of natural & synthetic
hormones, such as human growth
 HEART- muscles thicken, pumping
hormone slow the process.
rate & extraction of O2 from blood
3. Immunological theory- decline in
is diminished with age.
immune system functions lead to
 ARTERIES- stiffen, beat harder to
increased vulnerability to
supply the energy needed to propel
infectious dse. & aging.
blood caused by less elasticity of
ERROR THEORIES
arteries with age.
- It hypothesized that environmental
 LUNGS- maximum breathing
assaults the body’s constant need to
capacity declines about 40% bet
manufacture energy & fuel metabolic
the ages of 40 and 70.
activities cause toxic by-products to
 BRAIN- with age brain loses some
accumulate. These toxic by-products may
axons & neurons leading to deficits
eventually impair normal body function
in motor and sensory function.
& cellular repair.
 KIDNEYS- gradually become less
1. Wear & Tear Theory- this theory
efficient in removing waste from
believes that a “master clock”
the blood.
controls all organs & that cellular
 SIGHT- difficulty focusing close-
function slows down with time &
up may begin in the 40’s. @ 50
 becomes less efficient @ repairing accomplished at each stage. The
body malfunctions that are caused task of older adults includes ego
by environmental assaults. Abused integrity versus despair. Older
& neglect an organ or body system persons who have not achieved ego
stimulates premature aging or dse. ( integrity may look back on their
alcohol abuse leads to cirrhosis) lives with dissatisfaction & feel
2. Cross-Link Theory- an unhappy, depressed, or angry over
accumulation of cross-linked what they have done or failed to
proteins resulting from the binding do. Psychological counseling can
of glucose (simple sugars) to help resolve some of these issues.
protein (a process that occurs under SOCIOLOGICAL AGING THEORIES
the presence of O2) causes various This theory differ from biological theories
problems. Once binding occurs, because they tend to focus on roles &
protein cannot perform normally relationships that occur in later life.
results to visual problem (cataracts) 1. Disengagement Theory-(Cumming
or wrinkling of skin. & Henry 1961) this controversial
3. Free Radical Theory- accumulated theory asserts that the inappropriate
damage caused by oxygen radicals pattern of behavior in later life is
causes cells, & eventually organs, for the older person & society at
to loss function & organ reserve. large to engage in a mutual &
Anti-oxidants & vit. Can slow reciprocal withdrawal. Mandatory
damage. retirement forces some older
4. Somatic DNA Damage Theory- people to withdraw from work-
genetic mutations occur & related roles, accelerating the
accumulate with increasing age, process of disengagement.
causing cells to deteriorate & 2. Activity Theory- this theory
malfunction contradicts disengagement theory
PSYCHOLOGICAL AGING THEORIES by proposing that older adults
Most psychological theories advance that should stay active & engaged if
various coping or adaptive strategies must they are to age successfully.
occur for a person to age successfully. It Happiness & satisfaction with life
triggers might be physical changes of are assumed to result from a high
aging, issues of retirement, dealing with level of involvement with the
the death of a spouse or friends, & world & continued social
perhaps, declining health. involvement, according to this
1. Jung’s Theory of Individualism-it theory, when retirement occurs,
hypothesizes that as a person ages, replacement activities must be
the shift of focus is away from the found.
external world (extroversion) 3. Continuity Theory- successful
toward the inner experience aging involves maintaining or
(introversion). This stage of life, continuing previous values, habits,
older person will search for preferences, family ties, and all
answers to many of life’s riddles & other linkages that have formed
try to find the essence of the “true the basic underlying structure of
self”. To age successfully, the older adult life. According to this theory,
person will accept past the pace of activities may be
accomplishments & failures. slowed. Activities pursued in
2. Erickson’s Developmental Theory- earlier life that did not bring
there are 8 stages of life with satisfaction & genuine happiness
developmental tasks to be may be dropped @ the discretion
 of the older person. For some, contain specific criteria for
gaining relief from constant time defining expectations & competent
pressures & deadlines is one of the care associated with basic &
bounties of old age. advanced clinical practice of
gerontological nursing. These
GERONTOLOGICAL NURSING ISSUES standard applied in all clinical
 IN 1925 geriatrics, the medical practice settings.
specialty focusing on aging, began  In 1973, the first gerontological
to emerge. An anonymous column nurses were certified by the ANA
published in the American Journal to provide tangible recognition of
of Nursing called for nurses to professional achievement in a
consider “yet another specialty” defined functional or clinical area
 ANA is responsible in defining the of nursing.
scope & standards of nursing  CERTIFICATION- is a formal
practice. In 1966, the ANA process by which clinical
established the Division of competence is validated in a
Geriatrics Nursing Practice with specialty area of practice (ANA,
the mission of creating standards 2002). American Nurses
for quality nursing care for aging Credentialing Center (ANCC)
persons in all settings. support devt. Adm. Of cert. exam
 In 1976, the division’s name was by ANA.
changed to the Division on  The process consist of a written
Gerontological Nursing Practice to exam developed & reviewed by
reflect the idea that nursing care of nursing experts.
the older adult is holistic &  Certified nurses may be eligible for
emphasizes health as well as additional monetary compensation
common diseases of all age. & promotion or advancement.
 In 1970, ANA published a
Statement on the Scope of RESPONSIBILITIES OF
Gerontological Nursing Practice to GERONTOLOGICAL NURSE
define the nature & scope of  Direct care
current gerontological nursing  Management & development of the
practice & to address the concept professional & other nursing
of health promotion, health personnel
maintenance, disease prevention, &  Evaluation of care & services for
self-care. This document was the older adult
revised in 1981, 1987, 1995, & Note: all professional nurses practicing
2004. gerontological nursing need the basic
 The latest version involves knowledge & skills to perform the highest
collaboration bet. the ANA and level of care
selected members from several ANA REQUIRED KNOWLEDGE &
national nursing organizations and SKILLS FOR GERONTOLOGICAL
is intended to be a guide to current NURSES
practice in conjunction with other 1. Recognize the older adult may be
documents that articulate the values competent, & allow him or her to
of professional nursing. make healthcare decisions.
 The Scope & Standards of 2. Establish a therapeutic relationship
Gerontological Nursing Practice w/ the older adult to facilitate his or
(ANA 2001) apply to all prof. her involvement in developing the
nurses, the gerontological standards
 plan of care, which may include preserve the older adult’s dignity &
family participation as needed. peaceful death.
3. Use current gerontological 15. Embrace the surviving spouse &
standards to initiate, develop, & family members, providing
adapt the older adult’s plan of care strength, comfort, & hope.
while involving the patient, family, 16. Engage in continuing professional
& other providers as needed. development thru participation in
4. Recognize age-related changes continuing education, involvement
based on an understanding of in state & national professional
physiological, emotional, cultural, organizations, & certification.
social, psychological, economic, & 17. Use the standards of gerontological
spiritual functioning. nursing practice & collaborate with
5. Collect data to determine health other health care professionals to
status & functional abilities in improve the quality of care, quality
order to plan, implement, & of life of the older adult.
evaluate care.
6. Participate & collaborate with ANA COMPETENCIES
members of the interdisciplinary STANDARDS OF CLINICAL
team. GERONTOLOGICAL
7. Participate with older adults, NURSING CARE
families if needed, & other health Standard I: Assessment. The
professionals in ethical decision- gerontological nurse collects patient health
making that is patient centered, data. It involves functional ass.
empathetic, & humane. Environmental ass., physical; ass., & must
8. Serve as an advocate for older be culturally & ethnically appropriate.
adults & their families. Standard II: Diagnosis. The gerontological
9. Teach older adults & families about nurse analyzes the assessment data in
measures that promote, maintain, & determining diagnosis. It must be done
restore health & functional either independently or in collaboration
performance; promote comfort; & with interdisciplinary care providers. A
foster independence & preserve comprehensive diagnosis will be the basis
dignity. for care interventions.
10. Refer the older adult to other Standard III: Outcome Identification. The
professionals or community gerontological nurse identifies expected
resources for assistance as outcomes individualized to the older adult.
necessary. It must be focused on maximizing the
11. Identify common chronic/ acute aging person’s state of well-being,
physical & mental disease functional status, & quality of life.
processes that affect the older Standard IV: planning. The
adult. gerontological nurse develops a plan of
12. Apply the existing body of care that prescribes interventions to attain
knowledge in gerontology to expected outcomes. It must be develop in
nursing practice & intervention. conjunction with the older adult,
13. Exercise accountability to older significant others, & interdisciplinary team
adult by protecting rights & members.
autonomy, recognizing & Standard V: Implementation. The
respecting their decisions about gerontological nurse implements the
advance directives. interventions identified in the plan of care.
14. Facilitate palliative care & comfort It uses a wide range of culturally
during the dying process in order to competent direct & indirect interventions
designed to promote, maintain, restore 2. Nutritional- metabolic. Patterns of
health, prevent illness, rehabilitation, & food & fluid consumption relative
palliation. to metabolic need & nutrient
Standard VI: evaluation. The supply.
gerontological nurse evaluates the older 3. Elimination. Patterns of excretory
adult’s progress toward attainment of function & elimination of waste.
expected outcomes. It involves collection 4. Activity–exercise. Patterns of
of new data, revision of database, & exercise & daily activity including
modification of care plans which are leisure & recreation.
essential if needed. 5. Sleep-rest. Patterns of sleep, rest &
IMPORTANT ROLES OF relaxation.
6. Cognitive-perceptual. Patterns of
GERONTOLOGICAL NURSE
thinking & ways of perceiving the
 Advocate: advances the rights of world & current events.
older adult & educates others 7. Self-perception-self-concept.
regarding negative stereotypes of Patterns of valuing self (self-
aging. image)
 Educator: organize & provides 8. Roles-relationships. Patterns of
instructions about healthy aging, engagement with others, ability to
disease detection, treatment, & form & maintain meaningful
rehabilitation to older patients & relationship.
families. 9. Sexuality-reproductive. Patterns of
 Manager: maintains current & sexuality & satisfaction with
relevant information regarding present level of interaction with
federal & state regulations, & sexual partners.
provides nursing leadership in a 10. Coping-stress tolerance. Patterns
variety of healthcare settings. of coping with stressful events &
 Consultant: consult & advices level of effectiveness of coping
others who are providing nursing strategies.
care to older patients with complex 11. Values-beliefs. Patterns of beliefs,
healthcare problems. Participates in values, & perceptions of the
development of clinical pathways meaning of life that guide choices
& quality assurance standards & or decisions.
the implementation of evidence-
based practices. GERONTOLOGICAL NURSE ROLES BY
 Researcher: collaborates with
established researchers in the
SETTING
development of clinically based  SKILLED NURSING
studies. FACILITIES: (short stay) care
may be sub-acute, or chronic for
THE 11 FUNCTIONAL HEALTH frail patient requiring help with
ADL. (medicare re-inbursed or
PATTERNS private pay).
-it will guides the nurse in seeking  RETIREMENT COMMUNITIES:
information about the patient & helps in some are life care communities &
forming a crucial foundation in the care- offer coordinated independent
planning process. living in either apartment or
1. Health perception-health mgt. nursing home care. It includes
older individual’s perceived health leisure activities with 24 hrs. of
& well-being along with self-mgt. supervision if necessary.
strategies.
 ADULT DAY CARE: intended for  Provision of palliative care,
frail older patient requiring daytime including pain & symptom control,
supervision & activities. Some need for self- determination,
center offer transportation & other quality of life, & treatment
services such as monitoring blood termination.
pressure, blood sugar or even  Elimination of use of chemical &
PODIATRY (usually on private pay physical restraints.
basis). Patient confidentiality including
 RESIDENTIAL CARE electronic records.
FACILITIES: previously called  Surrogate decision-making.
rest homes. These type of facility is  Access to complementary
a large private home converted to treatments.
provide room for older residents  Fair distribution of resources.
who can provide most of their  Economic decision making.
personal care, but need help w/ BASIC ETHICAL PRINCIPLES
laundry. Supervision and health IN GERONTOLOGY
monitoring are usually provided.  BENEFICENCE/
 TRANSITIONAL CARE UNITS: NONMALEFICENCE: to do & not
many acute hospital established  JUSTICE: to be fair & distribute
transitional care units to provide scarce resources equally to all in
sub- acute care, rehabilitation, & need.
palliative care services to patient  AUTONOMY: to respect patient’s
who no longer require acute care. needs for self- determination,
(Post-op patient). Diagnostic & freedom, & patient’s rights.
support services can be provided if
necessary.
 REHABILITATION HOSPITALS ETHICAL DECISION MAKING
OR FACILITIES: a special facility  Nurse’s own value system will
to provide sub-acute care to patient influence all clinical & ethical
with complex health needs. May be decision-making.
patient w/ head injury or on  Nurse may also engage in ethical
ventilators, requiring aggressive inquiry to determine his/ her
rehabilitation after surgery or appropriate course of action
requiring intensive treatments from  Advances in healthcare technology,
specialist, physical therapist, changes in social & family system,
dietitians, or psychiatrist. the advent of managed care, & an
 COMMUNITY NURSING unlimited variety of healthcare
HOME: it requires home visiting choices have added to the
nurse to do skilled nursing care @ complexity of caring for the older
home, such as meds by injections, adult.
under supervision of primary  Decisional authority may be
physician. ultimately the older patient’s
ETHICAL ISSUES CONCERNED responsibility, the decision evolves
BY GERONTOLOGICAL NURSE w/in the therapeutic relationship
 Obtaining informed consent for with the nurse.
research & clinical treatment.  Nurse’s goal is to assist patient to
 Obtaining, clarifying, & carrying identify & articulate genuine
out advance directives. preferences & to make authentic
Appropriateness of emergency choices.
ETHICAL DECISION-MAKING
treatment.
COMPETENCY
 INVOLVES;  Try to be at eye level with the
1. Knowledge & skills- involves patient.
professional codes, professional  Try to minimize background noise
standards, identification of issues & as it can make it difficult from the
the law.
patient to hear.
2. Application- involves mediation,
facilitation of strategies to address
 Monitor patient reaction.
ethical problems.  Touch patient if appropriate &
3. Ethical environment- involves support acceptable.
from nursing adm., role models,  Supplement verbal instructions
mentors, & a system to address & with written instructions as needed.
rectify barriers.  Ask how the patient would like to
IMPORTANT ASPECT OF ETHICAL be addressed.
DECISION MAKING COMPREHENSIVE GERIATRIC
Assessment: it considers patient’s condition, EVALUATION
treatment goals, & treatment
Key part o geriatric evaluation is the
recommendations.
Relevant contextual factors: age, education,
functional assessment or systematic
life situation, family relationships, setting of evaluation of the older person’s level of
care, culture, religion, & socioeconomic function & self-care.
factors. It is usually interdisciplinary &
Capability of the patient to make decision: multidimensional & will address functions
legally competent, fluctuating mental status, in the;
presence of drugs or illness to cloud capacity. * physical
Patient preferences: signed advanced * social &
directives. * Psychological domains.
 Needs of the patient as a The key members of the interdisciplinary
person: psychic suffering, team are;
interpersonal dynamics, resources * Gerontological nurse
& coping strategies, adequacy of * Social worker &
the environment for care. * Geriatric physician
 Preference of the family: Other healthcare professional includes;
competence as surrogate decision * Physical therapist
maker, judgement & evidence of * Occupational Therapist
knowledge of patient preference, * Clinical pharmacist
opinions on quality of life. * Psychologist
 Competing interest: interest of * Psychiatrist
family, health providers, & futile * Podiatrist
utilization of scarce resources. * Dentist & others
 Issues of power or conflict: It must be done on a regular basis,
between clinicians & including;
family/patient, among family, * After hospitalization for an acute
among healthcare workers. illness.
 Opportunity for all involved to * When nursing home placement or a
speak & be heard: includes respect change in living status is being
for opinion. considered.
VERBAL COMMUNICATION * After any abrupt change in
GUIDELINES IN physical, social, or psychological
GERONTOLOGY function.
 Do not yell or speak too loudly to * Yearly for older person with
patient. complex health needs during the
annual visit.
 * When the older patient or family  Assembling group of knowledge
would like a second opinion enhance problem solving in the
regarding an intervention or delivery of care.
treatment protocol recommended  Coordination service enhanced by
by the primary care provider. professional working together.
 Patient will have access to
INSTRUMENTS USE IN comprehensive & integrated care
ASSESSING OLDER ADULTS plan.
 Cost effective & efficient
1. Lawton Activity of Daily Living: it
 Team feel supported & encourage
measure ability to perform tasks of
by input & collaboration from
personal care, including
other prof. preventing
ambulation, transferring, dressing,
“BURNOUT”
bathing, toileting, and continence.
2. Lawton Independent Activities of
Daily Living: it measures abilities COMPONENTS OF GERIATRIC
associated with living ASSESSMENT
independently in the community,  Despite variation in instruments,
including cooking, cleaning, structure of the interdisciplinary
laundry, shopping, using the team, & methods employed,
telephone, transportation, & several strategies have been proven
managing finances. to make the evaluation process
3. Pulse profile: it measures general more effective.
functional performance in mobility
 These includes development of
and self-care, medical status, and
close-knit interdisciplinary team
psychosocial factors;
with minimal redundancy in
P= physical condition
assessments performed using
U= upper limb function
questionnaire can be done by
L= lower limb function
caregivers.
S= sensory components
E= excretory functions
3 UNDERLYING PRINCIPLES OF
S= support factors
4. SPICES: an overall assessment COMPREHENSIVE GERIATRIC
tool used to plan, promote, & ASSESSMENT
maintain optimal function in older
adults; 1. Physical, psychological, &
S= sleep disorders socioeconomic factors interact in
P= problems with eating & feeding complex ways to influence the
I= incontinence health & functional status of older
C= confusion patient.
E= evidence of falls 2. Comprehensive evaluation of older
S= skin breakdown person’s health status requires an
assessment in each of these
REASONS FOR COLLABORATIVE domains. Coordinated effort of the
CARE FOR OLDER ADULTS team needed to carry out
 Complex problems requiring input assessment.
& advise from various healthcare
professionals.
3. Functional abilities should be
the central focus of the
comprehensive evaluation.
 COMPONENTS OF A 1. Review of acute & chronic
COMPREHENSIVE GERIATRIC problems
ASSESSMENT 2. Medications
1. CONTEXTUAL VARIABLES 3. Disease prevention & health
AFFECTING HOLISTIC maintenance review (vaccination,
GERITRIC ASSESSMENT: cancer screening)
-interrelationship between physical, 4. Functional status (ADL)
social, & psychological aspects of 5. Social supports ( family, caregiver
aging & perhaps illness present a stress, safety of living
challenge in evaluation. environment)
-the gerontological nurse often 6. Finances
charged of responsibilities in 7. Driving status & safety records
obtaining the past & present history 8. Geriatric review of symptoms
of patient illness. (patient/family perception of
CONTEXTUAL VARIABLES memory, dentition, taste, smell,
AFFECTING HOLISTIC GERITRIC nutrition, hearing, vision, falls,
ASSESSMENT fractures, bowel
a. Evaluation environment- to make & bladder function)
patient & family comfortable, POTENTIAL PROBLEMS IN
environmental modifications HEALTH HISTORY ASSESSMENT
should be made if possible. These 1. Communication difficulties:
includes; vision, hearing, slow speech, & use
 adequate lighting of english as second language have
 decrease background noise effect in communication.
 comfort of older patient 2. Underreporting of symptoms:
&accessibility to the restroom. fear of being labeled as complainer,
 examination tables that can be fear of institutionalization, fear of
raised or lowered to assist patient serious illness influenced symptom
with disabilities. reporting.
 availability of water or juice for 3. Vague & nonspecific complaints:
older patient these may be associated with
b. Accuracy of the health history: cognitive impairment, drug or
clear instructions must be provided alcohol abuse or atypical
to patient & family beforehand, presentation of dse. (alzheimer’s
including parking & registration dse.)
process. Some clinic uses mail 4. Multiple complaints: associated
information packets, sent to patient “masked” depression, multiple
in advance. This packet should chronic illness, & social isolation.
include the following; 5. Lack of time: new patient for
1. past medical history forms. assessment should have at least 1
2. instructions to bring prescribed hour scheduled appointment with
meds including OTC drugs used. GN.
3. instructions to bring all medical c. Social history: a holistic
records including lab. Test results. assessment is not complete without
4. instructions to write all healthcare this assessment. Support from
providers involved I the care of the family is needed to compensate
older patient. functional disabilities.
HISTORY INCLUDE EMPHASIS ON Key elements of the social history
THE FOLLOWING; includes;
 1. Past occupation & retirement accessibility for a refill of meds,
status. availability of the list of drugs for
2. Family history ( helpful to emergency use.
construct a family genogram) 4. Pre-determined wishes- copy of
3. Present & former marital status, health directives.
including quality of the 5. Nutrition & cooking- safety of
relationship(s) cooking & food, availability of
4. Identification of family members, microwave, adequacy of food,
with designation of level of proper food storage.
involvement & place of residence. 6. Falls- safety from falls such as
5. Living arrangements presence debris, cords, scatter rugs,
6. Family dynamics presence of pets, wearing of an
7. Family & caregiver expectations emergency alert system around the
8. Economic status, adequacy of neck if patient has history of fall.
health insurance 7. Smoke detector- a functioning
9. Social activities & hobbies smoke detector
10. 1Mode of transportation 8. Emergency numbers- posted or
11. Community involvement & support programmed in the telephone.
12. Religious involvement & 9. Temperature of home- check for
spirituality. adequate ventilation
d. Psychological history: 10. Temperature of water- hot water
psychological & cognitive function set below 120F.
is a key component of holistic 11. Safety of the neighborhood-
geriatric assessment. Unrecognized safety of the outside environment,
& untreated mental illness affect how close the nearest neighbor, can
complete evaluation & in designing get help if needed.
an appropriate nursing care plans. 12. financial- capability to pay bills, is
GN must establish a trusting there a large amount of cash stored
therapeutic relationship with the around the house?
older patient by the following
approach: f. Culture & education: an
1. caring increasing needs for health
2. warmth providers to care older adults from
3. respect & diverse backgrounds means that
4. support who older who are hesitant GN must consider how assessment
to verbalize feelings. & dev’t. of treatment are modified
e. Home environment: GN must to avoid misunderstanding or
have time & resources to visit & ineffective care.
conduct assessment of the -Assessment conclusion
environment where the patient live must be done from test
to gather an accurate data. scores or result considering
The following factors must be included; cultures & educational
1. stairs- proper lighting, railings, backgrounds of the patient.
uneven steps, ramps for wheelchair. -Low scores could falsely
2. Bathing & Toileting- proper be attributed to cognitive
lighting, grab bars, bath map, impairment rather low
raised toilet seat as needed, shower reading literacy.
seat. -GN should assess
3. Medications- how meds are stored, educational level, language
grandchildren is present, barrier, & cultural
 background prior to WHO defined health as “the state
assessment. of complete physical, mental, & social
well being and not merely the absence of
(MDS) MINIMUM DATA SET disease & infirmity”
 It is used to assess older person for the person is envisioned to move
appropriate placement in a long- back & forth on the continuum in response
term care facility. to a variety of factors.
 It is a comprehensive
multidisciplinary assessment tool GOALS OF INTERVENTION TO
used in the USA PATIENT WITH ALTERED HEALTH
 It was passed into law that will MAINTENANCE
facilitate improvement of care.
( the Omnibus Budget 1. Lifestyle changes
Reconciliation Act of 1987 (OBRA 2. Acquisition of new health-
87) promoting thought patterns &
behaviour
 Consist of a core set of screening,
3. Self-care in managing chronic
clinical, & functional measures.
health condition or risks.
 It is used with the Resident Ass
INDICATORS OF HEALTH BELIEFS
Protocol (RAPS), the Resident
 GN formulate indicators of
Utilization Guides (RUGS), & the
movements on the health
Resident Ass Instrument (RAI).
continuum, the following are
indicators of the older patients
beliefs on health;
1. Perceived importance of taking
CATEGORIES OF DATA GATHERED
action
FOR MDS
2. Perceived threat of inaction
1. Patient demographic & background
3. Perceived benefits of action
2. Cognitive function
4. Perceived internal control of action
3. Communication & hearing
5. Perceived control of health
4. Mood & behaviour patterns
outcome
5. Psychological well-being
6. Perceived improvement in lifestyle
6. Physical function & ADL
from action
7. Bowel & bladder continence
7. Perceived resources to perform
8. Diagnosed disease
action
9. Health conditions (weight, falls
8. Perceived absence of barriers to
etc.)
action
10. Oral nutritional status
9. Perceived reduction of threat from
11. Oral & dental status
action
12. Skin condition
13. Activity pursuits
BEHAVIOURS OF AN OLDER ADULT
14. Medications
THAT INDICATES STRONG
15. Need for special services
HEALTH BELIEFS
16. Discharge potential
1. Engaging in regular physical
1. HEALTH PROMOTION &
activity
DISEASE SCREENING:
2. Engaging in challenging mental
health may be considered as a state
activity
of physical, mental, & social functioning
3. Eating a healthy, balanced diet
that realizes the potential of which a
4. Getting 8 hours of sleep at night
person is capable.
 5. Having at least 1 friend to trust & Nursing care that violates the standard of
confide in practice can be considered malpractice.
6. Having some relaxing & pleasant
activities to look forward to OLDER PATIENT HAVE THE RIGHT
7. Having the self-discipline to enjoy TO;
pleasant things in moderation. 1. Received individualized care
8. Trying to view things positively & 2. Be free from abuse, neglect, &
have hopes for the future. discrimination
3. Be free from physical & chemical
2. HEALTH STATUS: it can restraints
be measured by birth & death 4. Have privacy
rates, life expectancy, quality of 5. Control their funds
life, morbidity from specific dse, 6. Be involved in decision making
risk factors, use of ambulatory 7. Raise grievances & make
care & inpatient care, complaints
accessibility og health personnel 8. Vote
& facilities, financing of 9. File lawsuits
healthcare, health insurance 10. Practice religion
coverage, & many other factors. 11. 1Marry
Additional recommendations 12. Participate in facility & family
include screening yearly for driving safety activities
& capability, elder mistreatment, alcohol 13. Have freedom to leave facility
use, falls, & financial problems. 14. Make a will & dispose property.
15. Enter into contract.
3. PAIN: it is an unpleasant sensory &
emotional experience that can SITUATIONS THAT CAN LEAD TO
negatively impact the quality of life of MALPRACTICE
older adult.
In verbal patient , the most accurate 1. Not adequately assessing or
evidence of pain & its intensity is based on monitoring
the patient’s description & self report. 2. patients as to change in condition.
In non-verbal patient, GN should 3. Not safeguarding the environment
carefully assess V/S, facial expressions, of a cognitively impaired patient.
resistance to movements, guarding of body 4. Not informing the physician that a
parts, & sighing or moaning. patient is in need of medical care.
Acute pain is a warning sign for 5. Medication errors
presence of serious undiagnosed illness or 6. Incorrectly performing a nursing
injury. intervention hat results in injury
Chronic unrelieved pain is 7. Failing to carry out positioning or
associated with hopelessness, depression, treatment.
& suffering. Patient are less likely to 8. orders, resulting in injury.
engage in rehabilitation activities, sleep
disturbances, & decreased in appetite. GUIDELINES IN DOCUMENTING
CARE AMONG ELDERLY
4. LEGAL ISSUES: GN must be
aware of the regulation, standard, & 1. Write clearly & legibly so others
laws that governs care for the elderly. can read the record w/out
Rights and dignity of the older patient struggling or ambiguity.
must be respected to avoid lawsuits. 2. Record all significant nursing
interventions & patient response.
 3. Record all significant nursing have the right to make informed
interventions withheld or deferred decisions about all care &
(eq. laxative not given as patient treatment unless they have been
has diarrhea) determined incompetent (unable to
4. Record any unusual event or make decision) by a court or law.
circumstances (falls, patient or Upon admission to healthcare facility
family comments, concerns) patient must sign consent for routine care
5. Record routine & on-going care such as bathing, dressing, feeding, &
6. Record conversations & phone administration of medications.
calls to physicians, advanced legality of consent must be considered.
practice nurses, families, diagnostic
facilities, & so on. FACTORS TO CONSIDER OLDER
7. Record recommended actions or PATIENT CAN PROVIDE CONSENT
inactions (no new orders received)
in response to phone calls &  Comprehend information
inquiries. (understand)
8. When taking verbal medication  Contemplate options (reason)
orders by phone.  Evaluate risks and consequences
9. Ask physician or advanced practice (problem solve)
nurse to fax information conveyed  Communicate that decision (make
in the telephone order if possible their decision known)
10. Record thoughts when any actions
are takenmor not taken as the result END OF LIFE ISSUES
of nursing judgements. (eq. oral
fluids are withheld because patient  When end of life is approaching, a
lacks gag reflex & in risk of variety of legal as well as issues
aspiration) emerge.
11. Do not scratch out, white out, enter  A health proxy, health directives, &
notes later, or obliterate any part of living is a concern.
patient’s record. (if an error is
 If a person has named a healthcare
made, draw a single line through
proxy to make a decision, health
the entry & write error or wrong
directives, or living will.
chart, & sign your name)
The healthcare professionals will
have guidance through decision
6. PATIENT CONFIDENTIALITY:
making process at the end of life.
7. USE OF TECHNOLOGY IN
ASSESSMENT: use of technology
BARRIERS TO THE COMPLETION
computer, fax machine is an issue
OF AN ADVANCE DIRECTIVES
to patient confidentiality in sending
medical records.
 Inability to speak english or
Fax machine should be used only when
primary language.
it is understood that the authorized
provider is the only receiver of the  Religious or ethnic beliefs.
confidential information.  Poor eyesight, cognitive
Patient must sign permission prior to impairment, hearing
copying, or sending a medical records  Standardized forms that are too
electronically to others. technical or print that is too small
to read.
8. INFORMED CONSENT &  Procrastination
COMPETENCE: older person
  Dependence on family for all patient’s culture, beliefs, practices,
decisions & language.
 Lack of knowledge about advance 2. Healthcare organizations should
directives implement strategies o recruit,
 Belief a lawyer is necessary retain, & promote at all levels a
 Fear of being written off or signing diverse staff & leadership.
life away 3. Healthcare organizations ensure
 Acceptance of the will of god. that all staff at all levels & all
across discipline receive on-going
CULTURAL DIVERSITY education & training in culturally
& linguistically appropriate service
  It has a significant implications delivery.
for healthcare delivery & making 4. Healthcare organizations must offer
policies in the care of elderly. & provide language assistance &
interpreter during all hours of
  All clinical practice areas- nurse
entire operations.
practitioner, doctor offices, clinics,
5. Healthcare organizations must
acute care settings, & long term
respect patient’s right to receive
care settings see this diversity
language assistance services.
everyday.
6. Healthcare organizations must
  Important to treat/care a more
provide a competent language
diverse patient as a result of
interpreter. Significant others not
demographic changes&
be use as interpreter unless
participation in insurance program,
requested by the patient.
interest in designing culturally &
7. Healthcare organizations must
linguistically appropriate services
make available easily understood
that lead to improving nursing care
patient-related signage.
outcomes, efficiency, & patient’s
8. Healthcare organizations should
satisfaction.
develop, implement, & promote a
written strategic plan that outlines
2 MAIN GOALS OF CULTURAL
clear goals, policies, operational
DIVERSITY
plans, & management
1. accountability/oversight
1. to develop cultural & linguistic
mechanisms to provide culturally
competence by nurses & other
& linguistically appropriate
healthcare providers.
services.
2. for healthcare organizations to
9. Healtcare organizations should
understand & respond effectively
conduct initial & on-going
to the cultural & linguistic needs
organizational self-assessments of
brought by both patients &
CLAS-related activities,
caregivers to the healthcare
encouraged to integrate culturally,
experience.
linguistically approach in care &
NATIONAL STANDARDS FOR
includes in assessment of patient
CULTURALLY &
satisfaction &evaluation.
LINGUISTICALLY APPROPRIATE
10. Healthcare organizations ensures
SERVICES IN HEALTH CARE (ANA)
an individual updated data of
1. Healthcare organizations should
patient in the information system
ensure that patients/consumers
based on culture, beliefs, &
received effective, understandable,
language spoken by the patient.
& respectful care compatible with
 11. Healthcare organizations should It grows from understanding of the ethno-
maintain a current demographic, cultural heritages, & life trajectories of the
cultural & epidemiological profile people involved in the Culture Care Triad.
of the community. Is composed of 3 distinct populations;
12. Healthcare organizations should 1. Nurse
develop participatory, collaborative 2. Patient &
partnerships with communities & 3. Caregivers
utilize a variety of formal &
2. informal mechanisms to facilitate ETHNO-CULTURAL HERITAGE
community & patient/consumer  It is predicated on the concept of
involvement in designing & heritage consistency. To describe
implementing CLAS-related the degree to which the person’s
activities. lifestyle reflects his or her
13. Healthcare organizations should respective tribal culture.
ensure that conflict & grievance  Theory expanded to the study the
resolution processes are culturally degree to which the person’s
& linguistically sensitive & capable lifestyle r eflects his/her traditional
of identifying, preventing, & culture.
resolving cross-cultural conflicts or  The concept of heritage
complaints by patients/consumers. inconsistency includes
14. Healthcare organizations are determinations of the ff;
encouraged to regularly make 1. Culture
available to the public information 2. Ethnicity
about progress & successful 3. Religion &
innovations in implementing the 4. Socialization
CLAS standards & to provide
public notice in their communities NUTRITION & AGING
about the availability of this
information.  Biological process of aging
proceeds at an individualized pace,
CULTURAL CARE NURSING yet predictable changes can place
 is a professional nursing care that is older persons at a disproportionate
culturally sensitive, culturally risk of under-nutrition or
appropriate, & culturally competent. malnutrition.
 the effects of these normal changes
Culturally sensitive- nurse posses a basic should be considered even in
knowledge of & constructive attitudes healthy individual.
toward health traditions observed.
Culturally appropriate- nurse applies CHANGES IN BODY COMPOSITION
background knowledge in the care of
older adults.  Lean muscle mass diminishes with
Culturally competent- nurse posses a aging, (sarcopenia) refers to these age-
complex combination of knowledge, related [Link] is due to the ff.
attitudes, & skills to deliver cultural reasons;
nursing care.  lessened physical activity.
 decreased anabolic hormone
CULTURAL CARE TRIAD
production (testosterone, growth
hormone,
Delivery of cultural care to elderly
 dehydroepiandrosterone)
population is extremely complex.
  increased cytokine activity & production is impaired increasing risk in
 decreased nutrition. uncompensated dehydration. characterized
by lethargy or confusion, w/ may be due to
ORAL & GASTROINTESTINAL restriction in fluid or accessibility of fluid
CHANGES WITH AGING to drink.

 Multiple changes may occur w/ age SENSORY CHANGES BRUOGHT BY

in regulation of both appetite & AGE AFFECTING NUTRITION OF
fluid status OLDER ADULT
 G.I. changes that may occur w/ [Link]- cataracts, macular degeneration,
aging can lead to altered dietary & general poor vision affect preparation &
intake & diminished nutritional enjoyment of food.( sensitivity to glare
status. lights)
  The following are factors 2. Hearing- w/hearing loss patient dine
brought by age that affect alone or isolate due to embarrassment or
nutritional status of older adults. frustration resulting to under nutrition.
  Specific interventions must be
done to help older adults cope with 3. Taste & smell- both senses diminish w/
these problems. age resulting reduced pleasure in eating.
These could be caused by meds
ORAL & G.I. CHANGES BRUOGHT (xerostomia), Parkinsonian syndrome
BY AGE AFFECTING NUTRITION results to loss of taste. Dysgeusia or altered
OF OLDER ADULT taste perception & complain of metallic &
1. Dentition- edentulism, poor dental chalky taste transmission are common
health, missing or loss teeth, & ill-fitting mostly ask for additional salt & sweets in
dentures can affect food eaten lead to food.
malnutrition. Mandibular bone loss due to
osteoporosis or periodontal disease SOCIAL & ECONOMIC CHANGES
affecting chewing. AFFECTING NUTRITION

2. Xerostomia- insufficient saliva  Retirement from workforce can

production, may be exacerbate by lead to a more sedentary lifestyle,
dehydration & medications. It could affect lead to decrease activity on body
taste perception & hinder swallowing. composition involving muscle loss
3. Atrophic gastritis- due to decrease in & fat gain.
size & number of glands resulting to lack  social isolation, loneliness, loss of
of hydrochloric acid production or spouse, & bereavement can alter
achlorhydria, common w/ age. Lack of Hcl adequacy of diet.
acid leads to mal-absorption of iron & vit  Poverty & near poverty or
B12. insufficiency of money for food.
4. Appetite dysregulation-
cholecystokinin production increase w/ age NUTRITIONAL & DISEASE-
can cause early satiety (anorexia of RELATED HEALTH CHANGES
aging). These caused by changes in gastric
emptying & central neurotransmitters Many chronic diseases that affect older
responsible for feeding drive. persons have nutritional implications of
5. constipation- due to less fluid intake, the disease & its treatment.
low fiber, meds, & lifestyle or inactivity.  cognitive impairment & mental illness,
6. Thirst dysregulation- aging blunts the such as dementia, depression, or anxiety.
thirst mechanism, & angiotensin
 Both disease process & medications can
affect appetite, taste, nutrient absorption,
& metabolism.