GERIATRIC NURSING

ASHIKA SEBASTIAN

Geriatric nursing: geriatric nursing is the speciality that concerns itself with the provision of nursing services to geriatric or aged individuals.

It is defined as the specialized nursing care of the older adults that occurs in any setting in which nurse use, knowledge, expertise and caring abilities o promote optimal functioning.

AGING: aging is defined as a maturational process that creates the need for individual adaptation because of physical and psychological declines that occurs during life time.

Chronological Age: refers to the number of years a person has lived. Easy to identify & measure, it is most commonly used objective method.

Physiological Age: refers to the determination of age by body function. Although age related changes affect every one, it is impossible to pinpoint exactly when these changes occur. That is why physiological age is not useful in determining a person’s age.

Functional Age: refers to a person’s ability to contribute to society and benefits others & himself. It is based on the fact that not all individuals of the same chronological age function at the same level.

FACTORS AFFECTING AGING

HEREDITORY FACTORS ENVIRONMENTAL FACTORS ABIOTIC FACTORS BIOTIC FACTORS SOCIOECONOMIC FACTORS

ANA STANDARDS OF GERONTOLOGICAL NURSING PRACTICE (NURSING CARE)

STANDARD I. Assessment: The gerontological nurse collects patient

health data. STANDARD II. Diagnosis: The gerontological nurse analyzes the

assessment data in determining diagnoses

STANDAR III. Outcome identification: The gerontological nurse identifies

expected outcomes individualize to the older adult.

STANDARD IV. Planning: develops a plan of cares that prescribes

interventions to attain outcomes. STANDARD V. Implementations: implements the interventions identified in

the plan of care. STANDARD VI. Evaluation: evaluates the older adults progress

towards attainment of expected outcomes.

ANA STANDARDS OF GERONTOLOGICAL NURSING PRACTICE (QUALITY CARE)

STANDARD I. Quality of Care: The gerontological systemically

evaluates the quality of care and effectiveness of nursing practice.

STANDARD II. Performance Appraisal: The gerontological nurse evaluates

his/her own nursing practice in relation to professional practice standards and relevant statutes and regulations

STANDAR III. Education: The gerontological nurse acquires and

maintains current knowledge in nursing practice.

STANDARD IV. Collegiality: contributes to professional development of

peers, colleagues and others. STANDARD V. Ethics: decisions and actions on behalf of older adults

are determined in an ethical manner.

STANDARD VI. Collaboration: collaborates with older adult, the older

adults caregiver, and all member of interdisciplinary team to provide comprehensive care.

13. STANDARD VII. Research: interprets applies and evaluates

research findings to improved gerontological nursing practice.

STANDARD VIII. Resource Utilization: considers the factors related to safety,

effectiveness and cost in planning and delivering patient care.

PRINCIPLES OF GERONTOLOGICAL NURSING PRACTICE

Aging is a natural process common to all living organisms.

Various factors influence the aging process.

Unique data and knowledge are used in applying the nursing process to the older populations.

The elderly share similar self-care and human needs with all other human beings.

Gerontological nursing strives to help older adults achieve optimum levels of physical, psychological, social and spiritual and spiritual health so that the can achieve wholeness

THEORIES OF AGING

Biological Theories of Aging-Biological theories attempt to explain physical aging as an involuntary process, which eventually leads to cumulative changes in cells, tissues and fluid.

Intrinsic Biological Theory-Intrinsic biological theory maintains that aging changes arise from internal, predetermined causes.

Extrinsic Biological Theory-Extrinsic biological theory maintains that environmental factors lead to structural alterations, which, in turn, cause degenerative changes.

FREE RADICAL THEORY

Free-radical theory emphasizes the mechanism of oxygen use at the cellular level. Free-radicals are molecule with an extra cellular charge. This charge creates a reaction that alters the structure or function of the cell membrane. Increased unstable free-radicals produces effect harmful to biological systems, such as chromosomal changes, pigment accumulation and collagen alteration

CROSS- LINKED THEORY

The cross-link theory and connective tissue theory asserts that the molecules of collagen and elastin, connective tissue components, from bonds that increase cell rigidity. Cross-linkage is thought to results from chemical reaction that creates chemical bonds between normally separate molecules in the body.

IMMUNOLOGICAL THEORY

the immune system is responsible for aging. An aging immune system is less able to distinguish body cells from foreign cells; as a result, it begins to attack and destroy body cells as if they were foreign. Erratic cellular mechanisms are thought to attack on body tissues through auto aggression or immunodefiency.

Error Theory: Error theory focus on the phenomenon of decreased bonding of protein cells that occurs spontaneously or in response to stressors such as radiation. This stressors results in errors in the synthesis of RNA and DNA and produces cells with impaired function.

Wear-and-Tear Theory: Body cells, structures and functions wear out or are over used through exposure to internal and external stressors. Effects from the residual damage accumulate, the body can so longer resist stress and death occurs. Repeated injury or overuse; internal and external stressors, including trauma, chemicals and build up of naturally occurring waste.

Somatic Mutation Theory: This theory suggests that cells exposed to chemicals or radiation results in alteration within the DNA molecule. Mutation results from these alterations accumulate overtime and become more evident with age and increasing cellular impairment

DNA Damage Theories: Aging is caused by accumulated damage to DNA, which in turn inhibits cells ability to function and express the appropriate genes. This lead to cell death and overall aging of the organism

Programmed Cellular Aging Theory: Suggest that aging may be result of an impairment of the cells in translating necessary RNAs as a result of increased turnoffs of DNA. In other words, the transcription of these messages into functional protein may be restricted in older people. Some segments of DNA become depleted with advancing age, or selected cellular structures seem to change with so that DNA transcription is restricted.

Psychosocial Theories of Aging: Psychosocial theories of aging attempt to explain age – related changes in cognitive function, such as intelligence, memory, learning and problem – solving

Disengagement Theory: This theory formulated by Cummings and Henry states that aging people withdraw from customary roles and engage in more introspective, self-focused activities. This theory includes 4 basic concepts:

Aging person and society mutually withdraw from each other.

Disengagement is biologically and psychologically intrinsic and inevitable.

Disengagement is considered necessary for successful aging.

Disengagement is beneficial for older adults and society

Continuity Theory: The continuity or developmental theory states that personality remains the same and behaviour become more predictable as people age. This theory focuses more personality and individual behaviour over time.

Activity Theory: Successful aging and life satisfaction depend on maintaining high level of activity. According to this perspective, the maintenance of optimal physical, mental and social activity is necessary for successful aging this theory also assumes that older adults have the same needs as middle-age persons

Adjustment Theory: Adjustment theory defines aging as a series of adjustment to retirement, to grandparenthood, to change in income, to changes in social life and marital status and to potential deterioration of health and well being.

Autoimmune theory: proposes that decrease in immune function may result in an increase in autoimmune response causing the body to produce antibodies that attack itself.

ASSESSMENT OF OLDER ADULTS

COMPONENTS1. FUNCTIONAL ASSESSEMENTKatz Index: It is for activities of daily

living is widely used for evaluating a patient’s ability to perform daily personal self care activities. This tool ranks the patient’s ability to perform six function: Bathing, Dressing, Toileting, Continence and Feeding

Barthel index: This type of tools helps to assess a patient’s capacity for self care. It evaluates 10 items: Feeding, Moving from wheel chair to bed and returning, Getting on and off the toilet, Walking on a level surface or propelling a wheel chair, going up and down stairs, dressing and under dressing, maintaining bowel incontinence and controlling bladder.

Lawton Scale: This is used for instrumental activities of daily living. This tool evaluates the patient’s ability to perform more complex personal care activities needs to support independent living, such as ability to use the telephone, shop, do laundry, manage finance, take medications and prepare meals.

OARS Social Resources Scale: The Older Americans Research Service Center[OARS] social resources scale is a multidimensional assessment tool developed at Duke University in 1978. It evaluates level of function in 5 areas: Social recourses, Economic resources, Physical health, Mental health and Activities of daily living.

2. PHYSICAL EXAMINATION

3. NUTRIONAL ASSESSMENT

AGE RELATED BODY SYSTEM CHANGES Musculoskeletal System Decreased muscle mass, size and

muscle look smaller. Decreased in muscle tone. Decreased amount of elastic tissue. Slower muscle response. Decrease in elasticity of tendons & ligaments. Decreased range – of – motion – stiffness. Decreased joint mobility. Osteoporosis – thinning and softening of the

bone.

Exaggerated bony prominence. Shortening of height as result of

intervertebral space narrowing caused by water loss

Synovial fluid becomes more viscous. Increased collagen formation, which

cause loss of resilience & elasticity in joints.

Integumentary System Increased dryness of skin. Thinning in the layer of the skin. Increased pigmentation, causing liver/

aging spot. Decreased elasticity of skin, causing

wrinkling. Decreased subcutaneous fat layer of skin. Decreased perspiration Facial lines around the eye, mouth and

nose. Hardness & dryness of nail, making them

more brittle.

Decrease in nail growth rate & strength. Toenails may discolour. Thinning of scalp hair. Decrease in melanin, which result in gray

hair. Hormonal changes cause pubic hair loss. Increased growth of nose, ear & facial hair. Slight growth of hair on upper lip & chin in

postmenopausal women. Decreased sebaceous & sweat glands,

which has implications for dryness & decreased temperature regulation.

Cardiovascular system Slowed heart rate. Reduced ability of the heart to quickly

increases its rate in response to an emergency because of thickening of heart valves, left ventricle and aorta.

Decreased stroke volume & cardiac output.

Decreased elasticity of blood vessels. Increased rigidity & thickening of

valves.

More irregular heart beats, arrhythmias, which leads to poor oxygenation of the heart.

Increased blood pressure – 140/90 – 160/100. Increased peripheral vascular resistance. More visible superficial blood vessels of legs. Common diastolic murmur. Weaken pedal pulse & colder lower

extremities.

Respiratory System Nose enlargement from continued cartilage

growth. Increased antero – posterior diameter. Increased chest rigidity. Increased respiratory rate with decreased

lung expansion. Decreased diffusion capacity of the lungs. Decreased total pulmonary surface area for

gas exchange. Decreased inspiratory & expiratory muscle

strength diminishes vital capacity.

Increased size of alveoli. Increased airway resistance. Decrease in lung’s elastic recoil

capability. Dilation of bronchioles & ducts. Weaker cough or gag reflex, Decreased depth of respiration &

oxygen intake.

Gastrointestinal System Decreased saliva production,

increased dryness. Changes in taste and smell. Decreased gag reflex. Decreased motility, peristalsis in

stomach. Decreased production of GI

secretions – HCL, Pepsin. Delayed gastric emptying.

No functional changes in small intestine.

Decreased tone in bowel wall & anal sphincter.

Alterations in bowel habits – constipation.

Decreased liver weight & Decreased blood flow.

Marked decline in liver enzymes which affects drug metabolism and detoxification.

Genitourinary System Decreased kidney size, function &

output. Decreased golmerular filtration. Reduced renal blood flow from decreased

cardiac output. Decreased efficiency of kidney to

concentrate urine. Diminished kidney filtration rate &

tubular function, which cause a decrease in the renal clearance of drugs.

Decreased number of nephrons. Decreased bladder size and tone. Incomplete bladder emptying &

chronic urine retention from weakness of bladder muscle.

Increased ease of backflow of urine. Decreased bladder capacity. Increased residual urine frequency &

nocturia. Increased incidence of UTIs. Increased plasma urea & uric acid.

Endocrine System Decreased pancreatic insulin release & peripheral

sensitivity. Decreased glucose tolerance with advancing age. Alteration in hormone production. Decreased secretion of estrogen, FSH & LH Decreased secretion of progesterone &

testosterone. Decreased production of rennin, angiotensin, &

erythropoietine. Decreased secretion of aldosterone contributes

to decreased sodium reabsorption Decreased secretion of ADH contributes to

decreased water reabsorption. Decreased secretion of thymosin & thyroxin.

Neurological System Progressive loss of brain cells. Decreased blood flow & oxygen

utilization to brain. Increased size of ventricles and

thinning of cortex. Decreased number of neurons,

neurotransmitters & nerve conduction. Increased length of dendrities &

number of synapse

Decreased reflex with increased nerve conduction rate.

Decreased ability of the hypothalamus to regulate body temp.

Decreased sense of balance or equilibrium.

Decrease sensitivity & sensation. Irregular sleep stages. Decreased motor coordination

response.

SENSORY SYSTEM Eye and vision Decreased visual acquity. Eyelids loss their elasticity. Conjunctiva become thinner& yellow. Quantity of tears decreases. Decreased pupil size & speed of

adjusting to change in light. Decreased ciliary muscle efficiency. Decreased accommodation due to

impaired lens elasticity. Lens enlarges and loses transparency.

Impaired colour vision. Sclera becomes thick & rigid and fat

deposits cause yellowing. Diminished night vision and depth of

perception.  Ears and Hearing Decreased elasticity of eardrum. Diminished hearing acquity. Decreased ability to hear high- pitched

sound. Gradual cerumen accumulation. Slowly progressive deafness- prebycusis

or senile deafness

Taste Decreased taste perception. Reduction in number of functioning taste

buds. Decreased amount of saliva. Smell Decreased sense of smell. Decreased number of olifactory neurons. Touch Decreased deep sensation. Decreased vibratory sense & pain

awareness. Decreased temperature regulation.

IMMUNOLOGICAL SYSTEM Decreased immune response. Decreased antibody response make

them more susceptible to infection. Decreased number & function of T-

cells.

REPRODUCTIVE SYSTEM Male reproductive system Decreased testosterone production cause

decrease libido. Decrease size and firmness of testes. Prostate gland enlarges and secretion

decreases. Seminal fluid decreases in volume& less viscous. Decreased intensity of sensation. Decreased speed of erection & force of

ejaculation. Decreased sperm count. Increased dysuria.

Female reproductive system Decreased vaginal lubrication, dry, pale, and less

elastic. Thinning & shortening of vaginal wall. Vaginal acidity reduced. Decreased size of labia and clitoris. Decreased quantity of pubic hair. Ovaries atrophy and become thinner & smaller. Uterus becomes smaller and less firm. Decreased secretion of estrogen, progesterone, FSH&

LH Cessation of menses after menopause. Breasts become pendulous. Nipples decrease in size and become flat. Glandular, supporting & fatty tissue atrophy. Degenerative changes in the gonads lead to abrupt

cessation of the menses

COGNATIVE CHANGES OF NORMAL AGING

Factors affects cognition Sensory changes and disease associated

with ages. Pain from chronic disease Sleep deprivation Medications side effects Changes in mental functioning range of interests, and understanding. Increased repetitive thoughts and

vulnerability to stress.

Changes in memory Short –term memory, which is associated with

decreased judgement, insight, and orientation. Gradual memory loss Learning and intelligence Aging may affect learning. Hesitancy in answering questions or repeating

information. Intelligence does not declines as on age.

PSYCHOSOCIAL ASPECTS OF AGING

RETAIREMENT

ROLE CHANGES

LONELINESS

DEPRESSION AND SUICIDE

COMMON MEDICAL PROBLEMS IN OLD AGE

PRESSURE ULCERS Prevention of pressure ulcers Monitor the pressure areas by measuring

length, width and depth of to gauge of the ulcers

Turn the patient ever two hours Keep the patient skin clean and dry Place the pillow between the pressure areas

to prevent friction and pressure Teach the active and passive exercises Use paper tape to secure dressing

CARDIOVASCULAR DISEASES RESPIRATORY DISEASES GENITOURINARY SYSTEM urinary incontienence

GASTROINTESTINAL DISEASES interventions

Promote normal bowel elimination. Remove faecal impactions. Palpate patients abdomen and

auscultate for bowel sounds Monitor the patent use of laxative

and enema.

NEUROLOGIC DISEASESInterventions: Watch for anxiety Speak to the patient slowly in a soft

and clam voice. Assess the patients needs for

assistance. Give the patient plenty of time to

complete task. Provide small frequent feeding Assess the patient ability to swallow

ENDOCRINE DISEASES Interventions: Obtain current weight and weight

history of the patient. Assess signs for hypoglycaemia Monitor intake and out put Administer intravenous insulin Administer intravenous fluid Explain all the procedure to the

patient

MUSCULOSKETAL DISEASESInterventions: Assess the signs and symptoms of pain. Apply ice pack to the joint Administer acetaminophen Teach the patient about active and

passive exercise Encourage the patient to avoid walking

down stairs Teach the patient to organize the

activities of daily living.

MEDICATION IN ELDERLY

Major problems with prescriptive medication include adverse effect, medication intervention, medication errors, non compliance and cost.

Determine the use over the counter medications.

Polypharmacy

Medication dosage normally as prescribed at one third to one half of normal adult dose.

Closely monitor client for adverse effect& response to therapy because the increased risk for medication toxicity.

Note that a common sign of an adverse effect in the older client is an acute change in mental status.

Asses for medication interaction in the client taking multiple medication.

Advise the client to use one pharmacy & notify the consulting physician of the medication taken.

Administration of medication Place the client in a sitting position when

administering medication taken. Check for mouth dryness because

medication may stick & dissolve the mouth.

Administer liquid preparation if the client has difficulty in swallowing.

Crush tablets if necessary & give with textured food, if not contraindicated.

Do not crush –entric- coated tablets& do not open capsules.

Do not crush –entric- coated tablets& do not open capsules.

If administering a suppository do not insert suppository immediately after removing the refrigerator.

A suppository may take longer time to dissolve because decreased body core temperature.

When administering parentral medication, monitor the site it may ozze medication or bleed because of decreased tissue elasticity.

Do not use an immobile limb for administering parentral medication.

Monitor client compliance with taking prescribed medication.

Monitor client for safety in correctly taking medications including an assessment of their ability to read the instructions & discriminate among the pills& their colour & shape.

Use medication cassette to facilitate proper administration of medication.

ABUSE OF THE OLDER ADULTS

Abuse involves physical emotional or sexual abuse & also can involve neglect or economic exploration

Categories of mistreatment domestic mistreatmentInstitutional mistreatmentSelf neglect

STRESS AND COPING IN ELDERLY Common stressors of old age include: Normal aging changes that impair physical

function, activities and appearance. Disabilities and chronic illness. social and environment losses of income,

roles and activities. Death or illness of significant others. Physical and sexual abuse. Depression, heavy drinking, or insufficient

sleep. Social issues, such as social defeat, or

relationship conflict.

Some suggestions may help to reduce the stress

Take one think at a time. Be realistic Visualization – imagination hoe you can

manage a stressful situation. Meditation – 5-10 min of meditation can bring

some relief. Exercise Hobbies Be flexible and clam Adopt healthy life style Share feelings with family members or friends.

USE OF AIDS AND PROSTHESIS

PROSTHESIS: Prosthesis is an artificial device used to replace a missing body part such as a limb, tooth, eye or heart valve. Prosthesis refers to the replacement of the missing body part with such a device. In medicine, prosthesis is an artificial extension that replaces a missing body part.

DENTAL PROSTHESIS: is an artificial appliance which is used as a substitution for the replacement of teeth. In certain conditions of missing teeth empty space between teeth can lead to teeth shifts to compensate for the space.

ADVANTAGES Mastication: chewing ability is improved by

replacing edentulous areas with denture teeth. Aesthestics: the presence of teeth provide a

natural facial appearance, and wearing a denture to replace missing teeth provides support for the lips and cheeks and corrects the collapsed appearance that occur after losing the teeth.

Phonetics: by replacing missing teeth, especially the anteriors patients are better able to speak by improving pronunciation of those words containing siblints or fricatives.

Self esteem: patients feel better about themselves.

HEARING AIDS

A hearing aid is an electroacoustic body worn apparatus which typically fits in or behind the wearer’s ear and is designated to amplify and modulate sound for the wearer. Earlier devices, known as an “ear trumpet’ or “ear horn”.

TYPES OF HEARING AIDS

POCKET MODEL BEHIND THE EAR(BTE) IN THE EAR(ITE) IN THE CANAL, (ITC)MINI CANAL ( MIC),

COMPLETELY IN THE CANAL(CIC) SPECIAL TYPE REMOTE MICROPHONE BONE CONDUCTION HEARING AIDS

Care and maintenance of hearing aids

Prevent it from falling down Don’t spill liquids on the hearing aids The hearing aids should be fitted well Cords should not be twisted or knotted Protect it from dust, dirt &heat Remove the battery from hearing aids

when it is not in use The receiver should not come in contact

with water

Acute Care Gather medical, family and psychological history Perform patient assessment Explain diagnosis and treatment to the patient and family Work closely with patient, family, and other health care

professionals to develop a good nursing care plan suitable for each patient.

Foster elderly patients independence Provide medication and treatments and evaluate responses Maintain hydration, nutrition, aeration and evaluate

response Administer emergency treatment when necessary Initiate discharge planning & coordinate referral to

community agencies. Serve as patient advocate Inform doctor of any change patient condition

Long Term care Gather medical, family, and psychological history Perform patient assessment Involve patient and family preparation and

implementation of nursing plans. Promote the atmosphere that emphasises quality living,

not diseases and dying. Ensure that patient receives, medical, dental and eye

care. Maintain hydration, nutrition, aeration comfort of elderly. Provide medications, treatments, rehabilitative exercises

and evaluate responses. Treat and advice patient and family. Become knowledgeable person and refer the patient and

family to appropriate sections. Perform emergency measures when necessary. Inform doctor of change of patients condition.

Community care Identify health, social, or economic needs Refer elderly person to professional or other

agencies, to suit their needs. Explain diagnosis and treatment to patient and

family Evaluate compliance with response to treatments Use clinics and home visits for health promotion Teach and advise patient and family Evaluate elderly persons ability to live

independently Become advocate for elderly persons Encourage elderly person to become advocate on

his own behalf.

SPECIAL CONSIDERATIONS IN CARE OF ELDERLY Promotion of self respect and dignity Promotion of comfort Safety Daily living activities Promotion of independence Promotion of movement and mobility Use of meditation in elderly rehabilitation

LEGAL AND ETHICAL ISSUES Informed consent Autonomy Euthanasia Assisted suicide Palliation

COMMUNITY AND INSTITUTIONAL HEALTH CARE SERVICES

HOME CARE: home care is a range of health & supportive services provided in the home for people who require assistance in meeting their health care needs. These agencies may be governmental, private or voluntary.

HOSPICE CARE: A hospice is a resources for the terminally ill. A hospice can be independent unit within the community that provides support to the client & family in the home or it may be contained within an institution. The programme focused on meeting the needs of the dying patient and family.

RESPITE CARE: Respite care provides caregiver relief for a brief, time – limited period. It can be offered in the home, through a day care program or within a facility or institution. An advantage in the home, is that the patient is familiar with physical environment.

DAY CARE: Day care provides an alternative to institutionalization. Offering health & rehabilitative services. Day care center clients are usually not seriously ill, although they may have chronic conditions or disabilities that limit independence. These individuals cannot be left alone during the day when family members are at work or unavailable.

SENIOR CENTERS: Senior centers offer a variety of social, health, and nutritional , educational and recreational services. They give older people the opportunity to gather for social activity. Besides being meting places, senior center offers councelling, special trips, legal services & advice on financial matters.

CHECK – IN SERVICE: Some senior centers, churches and other community agencies offer telephone check – in services, in which a volunteer phone a client at a certain time each day to ascertain his status & to provide social contact.

LONG TERM CARE: It refers to a continuum of services, including medical care, nursing care & personnel or psychological services. Long term care services provide care for people at varying levels of dependence who will require care for an extended period.

EMERGENCY RESPONSE SYSTEM : ERS provide a link between the elder living alone & emergency services. The ERS when activated can dispatch police an ambulance or other appropriate services to the individuals home. ERS alarm may warn as jewellery, may be attached to the telephone or may be placed next to the bed or bathroom.

NURSING DIAGNOSIS

Social isolation related to inadequate individual resources

Health seeking behaviours related to home safety measures that prevents falls

Impaired home maintence management related to inadequate social support system

INTERVENTIONS Actively listen to the client Give positive reinforcement Helps the client to explore the causes of

social isolation Assist the client to develop a plan of action Assess the client’s home for safety hazards Explore the health status of all family

members Initiate referrals Arrange for additional support for care

givers

Nursing Diagnosis Risk for impaired ski integrity related to

urinary incontinenceINTERVENTIONS Assess the perineal area for signs of skin

breakdown Change the continence pad immediately

after an episode of urinary incontinence Provide proper perineal care. Apply a moisture cream barrier to the

perineal area Instruct the female patient to avoid using

feminine hygiene products

Nursing diagnosis Self – care deficit related to

increased forgetfulness secondary to disease progression

Intervention Assess patient need for assistance Give the patient plenty of time to

complete task Maintain or ensure physical activity as

tolerated and range of motion exercise to maintain mobility

THANK YOU