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Gerontological Nursing

Jose Karlo M. Pañgan,RN, MAN

Week One

INTRODUCTION TO GERONTOLOGIC NURSiNG

GERONTOLOGYNURSING

WEEK ONE

GERONTOLOGY From the Greek word

Geron, “old man

The scientific study of the process of aging and the problems of aged persons; includes biologic, sociologic, physiologic, psychologic, and economic aspects

 

“Gero” – old age;“Ology” - study of

Older Age Group:Young Old – ages 65-74Middle Old – ages 75-84Old Old – 85 and up.

TERMINOLOGIES

Gerontophobia – fear of aging. Inability to accept aging adults in the society.Age Discrimination – emo-prejudice among the older adult.Ageism – dislike of the aging and the older adult.

Geriatrics – generic term relating to the aged, but specifically refers to medical care for the aged.

Social Gerontology – concerned mainly with the social aspects of aging versus the biological or psychological

Geropsychology – refers to the specialists in psychiatry whose knowledge, expertise and practice are with the older population.

Geropharmaceutics – also called Geropharmacology is a unique branch in which pharmacists obtain special training in geriatrics.

Financial Gerontology – combines knowledge of financial planning and services with a special expertise in the needs of older adults.

Gerontological Rehabilitation Nursing –

combines expertise in Gerontologic nursing

with rehabilitation concepts and practice.

Gerontological Nursing – the aspect of

gerontology that falls within the discipline of

nursing and the scope of nursing practice.

ROLES OF THE GERONTOLOGIC NURSE

Provider of careTeacherManagerAdvocateResearch Consumer

DEMOGRAPHICS OF OLD PEOPLE

“Graying of America” - a phenomenon faced by all nations, not only the U.S.

Demographic Tidal Wave or A pig in a Python – a bulge in the population moving slowly through times. (1946-1964 : Baby Boomer)

DEMOGRAPHICS OF OLD PEOPLE

By year 2010, the number of persons 65 and older in the United States is at 39 million: 13% of the population. By 2010-2030, it is expected that 65 year olds will be more than 79 million.

Women comprise the majority of the older population in all nations (55%), and the majority of these women (58%) live in developing countries.

Marital Status An important determinant of health

and well- being, it influences income, mobility, housing, intimacy, and social interaction.

Gender Women live longer than men due to

reduced maternal mortality, decreased death rate from infectious diseases, and increase death rate in men from chronic diseases.

Women are likely to poor, alone, and greater degree of functional impairment and chronic diseases.

Living Arrangement and Housing

A person’s overall degree of health and well-being greatly influences the selection of housing in old age. Ideal housing promotes functional independence while emphasizing safety and social interaction needs.

Geographic Distribution

Older adults are less likely to change residence than other age-groups. “Aging-in-place”.

Education The educational level of older adult

clients affects the nurse-client health teaching process and an important consideration in health promotion and disease prevention.

Income and Poverty Major source of income is SSS, and

other supplemental income like assets, public and private pensions, earnings and public assistance.

Income affects health and lifestyle – people are unable to meet basic needs and typically reduced the amount of spending in health-related matters.

Employment

Two-thirds of older, self-employed workers were men. The labor force participation of older men has remained fairly constant

Functional Status Functional ability is of

greater concern to older adults and the nurses than the incidence and prevalence of chronic diseases.

Functional ability – the capacity to carry out the basic self-care activities that ensure overall health and well-being.

ADLs: Bathing, Dressing, eating, transferring and toileting;

InstrumantalADLs: shopping, cooking, housekeeping, laundry and handling money.

Nurse should determine the plan of action on impact of chronic diseases. Improvement and Prevention are the keys.

Implications to Health Care Delivery

Create roles that meet the needs of the older people, across the continuum of care

Develop models of care directed at all levels of prevention with emphasis on primary prevention and health promotion services in the Community-Based Setting.

Assume leadership, in health care and in political arena.

SETTINGS OF CARE

Acute Care SettingOnly few hospitals can adequately

manage acute conditions by preventing functional decline:

IMPLICATION persons.: hospital setting continues to be one of the most dangerous for older

The point of entry to the health care systems for older adults.

In this setting, Gerontologic Nurses focus on treatment and nursing care of acute problems such as those occurring from trauma, accidents, orthopaedic injuries, respiratory ailments or serious circulatory problems.

Long Term Care/Nursing Facilities

Include Assisted Living, Intermediate care, subacute or transitional care skilled care and Alzheimer’s unit.

Assisted Living / Home Care

Provides an alternative for those older adults who do not feel safe living alone, who wish to live in a community setting or who need some additional help with the activities of daily living.

Intermediate Care

Level of care provides 24 hour per day direct nursing contact and may be considered to be the entry level into the nursing home care.

Subacute or Transitional Care

generally for patients who require more intensive nursing care than the traditional nursing home can provide but less than the acute care hospital.

 Nurses Requirement

Understanding of the normal and abnormal aging

Strong assessment skills to detect subtle changes that may indicate impending, serious problems

Excellent communication skills especially with DDD patients.

Keen understanding of rehabilitation principles

Sensitivity and patience.

LEADING CAUSE OF MORTALITYHeart DiseasesMalignanciesCerebrovascular diseaseChronic lower respiratory diseases Influenza and PneumoniaDiabetes Mellitus

LEADING CAUSE OF MORBIDITYArthritisHypertensionHeart DiseasesHearing ImpairmentsCataractsOrthopedic impairmentsSinusitisDiabetes

Theories of AgingBiological

Stochastic and Non-stochasticSociologicalPsychological

THEORIES OF AGING: I. STOCHASTIC THEORIES

Based on random events that cause cellular damage that accumulates as the organism ages.

  II. NON STOCHASTIC THEORIES OF

AGING Based on the genetically programmed

events that cause cellular damage that accelerates aging of the organism.

I. STOCHASTIC THEORIESFree Radical Theory

Membranes, Nucleic acids and proteins are damaged by free radicals which causes cellular injury,

Exogenous Free radicals: Tobacco smoke, Pepticides, organic solvents, Radiation, ozone and selected Medications.

Health TeachingDecrease calories in order to lower

weightMaintain a diet high in nutrients

using anti-oxidantsAvoid inflammationMinimize accumulation of metals in

the body that can trigger free radicals reactions.

Older adults are more vulnerable to free radicals.

Orgel/ Error Theory

Errors in DNA and RNA synthesis occurs with aging.

Wear and Tear TheoryCells wears out and cannot function

with aging.Like a machine which losses function

when its parts wears off.

Connective Tissue Theory / Cross-linkage theory

With aging, proteins impede metabolic processes and cause trouble with getting nutrients to cells and removing cellular waste products.

II. NON STOCHASTIC THEORIES OF AGINGProgrammed Theory/ Haylick Limit TheoryCells divide until they are no longer

able to and this triggers to apoptosis or cell death.

Shortening of the TELOMERES – the distal appendages of the chromosomes arm.

TELOMERASE – an enzyme, “cellular fountain of youth”

Gene/ Biological Clock Theory Cells have a genetically

programmed aging code.

Neuroendocrine control or pacemaker theory Problems with the hypothalamus-

pituitary-endocrine gland feedback system causes disease.

Increased insulin growth factor accelerates aging.

 Immunologic/ Autoimmune Theory

Aging is due to faulty immunological function, which is linked to general well-being.

SOCIOLOGIC THEORIES OF AGINGAttempt to explain aging in terms

of behaviour, personality and attitude change.

SOCIOLOGICAL THEORIES

changing roles, relationship, status and generational cohort impact the older adult’s ability to adapt.

Activity theory Havighurst and Albrecht

(1953)Remaining occupied and

involved is necessary to satisfy late life.

Activity engagement and positive adaptation.

Disengagement Theory Cumming and Henry (1961)Gradual withdrawal from society and

relationships serves to maintain social equilibrium and promote internal reflection.

Continuity Theory Havighurst (1960)also known as Development

TheoryPersonality influences role and

life satisfaction and remains consistent throughout life.

Age Stratification Theory

Riley (1960)Society is stratified by

age groups that are the basis for acquiring resources, roles, status and deference from others.

Person-Environment Fit Theory

Lawton (1982) Function is affected by ego strength, mobility, health,

cognition, sensory perception and the environment.

PSYCHOLOGICAL THEORIES OF AGING

Explain aging in terms of mental processes, emotions, attitudes, motivation, and personality development that is characterized by life stage transitions.

Human needsMaslow’s (1954)Five basic needs motivate

human behaviour in a lifelong process toward need fulfilment.

Self – Actualization

Individualism Theory Jung (1960) Personality consists

of an ego and personal and collective unconsciousness that views life from a personal or external perspective.

Stages of Personality Development Erikson (1963) Personality develops in eight

sequential stages with corresponding life tasks. The eighth phase, integrity versus despair, is characterized by evaluating life accomplishments; struggles include letting go, accepting care, detachment, and physical and mental decline.

Selective optimization with compensation

individuals cope with aging losses through activity /role selection, optimization and compensation.

GERONTOLOGIC ASSESSMENT Learning Objective: Explain the relationship

between physical and psychosocial aspects of aging as it affects the assessment process.

Special Considerations affecting assessment Interrelationship between Physical and

Psychosocial aspects of aging. Nature of Disease and disability and their effects

on functional status Tailoring the nursing assessment to the older

person The health history Additional assessment measures

PRINCIPLES OF ASSESSMENTUse of an individual, person-centered

approachView of clients as participants in

health monitoring and treatmentAn emphasis on clients’ functional

ability

Note: Nursing-Focused Assessment should be scientifically based-knowledge and always practice to acquire the art of assessment.

Environmental factors

Health Status

Effects of Selected Variables on Functional Status

Variable Eff ect

Visual and Auditory Loss

ApathyConfusionDisorientationDependencyLoss of Control

Multiple strange and unfamiliar

environments

ConfusionAgitationDependencyLoss of controlSleep disturbanceRelocation Stress

Acute medical Illness

Mobility impairmentDependencyLoss of ControlSleep DisturbancePressure UlcerInadequate food intake

Altered pharmacokinetics and

pharmacodynamics

Persistent confusionDrug ToxicityPotential for further mobility impairmentLoss of functionAltered patterns of bowel and bladder eliminationLoss of Appetite: affects healing, Bowel function, energy level; dehydrationSleep disturbance

Problem Classic Presentation Elderly patients

Urinary Tract Infections

Dysuria, frequency, urgency, nocturia

Dysuria often absent, frequency, urgency, nocturia sometimes present. Incontinence, delirium, falls, and anorexia are other signs

Myocardial Infections

Severe substernal chest pain, diaphoresis, nauseam dyspnea

Sometimes no chest pain,or atypical pain location: jaw, neck, shoulder, epigastric area. Dyspnea, may or may or may not be present. Tachypnea, arrtyhmia, hypotension, restlessness, syncope, and fatigue/weakness. Fall

Bacterial Pneumonia

Productive cough and purulent sputum, chills and fever, pleuritic chest pain, ↑WBC

Cough: productive, dry or absent; chills and fever and or ↑ WBC may be absent. Tachypnea, slight cyanosis, delirium, anorexia, NV, tachycardia.

CHF ↑ dyspnea,fatigue, weight gain, pedal edema, nocturia, bibasilar crackles

ALL and/or anorexia, restlessness, delirium cyanosis, and falls.Cough.

Hyperthyroidism

Heat intolerance, fast pace, exophthalmos, ↑ pulse, hyperreflexia, tremor

slowing down (apathetic hypo), lethargy, weakness, depression, atrial defibrillation, and CHF

Hypothyroidism

Weakness, fatigue, cold intolerance, lethargy, skin dryness, and scaling, constipation

Often w/o over symptoms. Majority of Cases Subclinical. Delirium, dementia, depression/lethargy, constipation, weight loss, muscle weakness/unsteady gait are common.

Depression Dysphoric Mood and thoughts, withdrawal, crying, weight loss, constipation, insomnia

Classic symptoms may or may not be present.Memory and concentration problems, cognitive and behavioural changes, increased dependency, anxiety and sleep. Be alert for CHF, CA, DM, infectious diseases, and anemia. Cardiovascular agents. Anxiolytics, amphetamines, narcotics and hormones can also play a role. 

2.2 NATURE OF DISEASE AND DISABILITY AND

THEIR EFFECTS ON THE FUNCTIONAL STATUS

Aging does not necessarily result in diseases and disability

Chronic diseases increases older adults’ vulnerability to functional decline

Common Mistake: Nurses and adults attribute vague signs and symptoms as normal signs of “growing old”.

A comprehensive assessment of physical and psychosocial function is important because it can provide valuable clues to a diseases’ effect on functional status.

Nursing Action: Identify NORMAL VS. ABNORMAL: dependable benchmarks of health are previous laboratory findings

Watch out for vague signs and symptoms: do not ignore and look for non-specific signs.

2.2.1 Decreased Efficiency of homeostatic Mechanisms

The older persons’ adaptive reserves are reduced- results in decreased ability to respond to physical and emotional stress.

Immunocompetence is affected by multiple factors.

Adults repeatedly encounters losses: needs time to recover between losses and recuperation. The shorter time interval between losses, the lesser ability to respond and return to baseline stage of health compared to younger people.

Nursing ActionAssess older adults for presence

of physical and psychological stressors and their physical and emotional manifestations.

 Lack of Standards of Health and illness

Difficulty arises on identifying the health status of older adults due to:

Norms or standards are always redefinedPolypharmacy and state of illness and

disease may affect laboratory data.No aging norms for many pathologic

conditionsThere are few landmarks for stages of

development for the older adulthood compared to other age groups.

Nursing Action: Assume heterogeneity rather

homogeneity: uniqueness of personal health standards.

Look for previous health history and related matters: previous work, residence, lifestyle etc.

Compare presenting signs and symptoms with the older adults’ normal baseline.

COGNITIVE IMPAIRMENT

Delirium – one of the most common, atypical presentations of illness in older adults.

Confusion, mental status changes, cognitive changes and delirium –

used to describe one of the most common manifestations of illness in old age.

Acute Confusional State (ACS)- an organic brain syndrome

characterized by transient, global cognitive impairment of abrupt onset and relatively brief duration, accompanied by diurnal fluctuation of simultaneous disturbances of the sleep-wake cycle, psychomotor behavior, attention, and affect”( Foreman, 1986)

Dementia – a global, sustained deterioration of cognitive function in an alert client.

Other manifestations: memory impairment, aphasia, apraxia, agnosia, or disturbance in executive functioning; planning, organizing, sequencing and abstracting.

Primary dementia Senile dementia of Alzheimer’s type, Lewy body disease, Pick’s Disease, Creutzfeldt-Jakob Disease and multi-infarct dementia

Secondary Dementia

Normal pressure Hydrocephalus, intracranial masses or lesions, pseudodementia, and Parkinson’s dementia.

Differentiating Dementia and ACS

FEATURE ACS DEMENTIA

ONSET

Acute/subacute; depends on cause; often occurs at twilight

Chronic, generally insidious; depends on cause

COURSE

Short, diurnal fluctuations, worse at night, dark and awakening

Long, no diurnal effects, symptoms progressive, stable

DURATIONHours to less than 1 month

Months to years

AWARENESS

Fluctuates, generally reduced

Generally Clear

ALERTNESSFluctuates, reduced or increased

Generally normal

ATTENTIONImpaired, often fluctuates Generally normal

ORIENTATION

Fluctuates, in severity, impaired

May be impaired

MEMORY

Recent and immediate memory impaired; unable to register new information or recall recent events

Recent and remote memory impaired; loss of recent memory is 1st sign; some loss of common knowledge

THINKING

Disorganized, distorted, fragment, slow, or accelerated

Diffi culty with abstract and word finding

PERCEPTION

Distorted, illusions, delusions, or hallucinations

Misperceptions often absent

SLEEP-WAKE CYCLE

Disturbed, cycle reversed Fragmented

TAILORING THE NURSING ASSESSMENT TO THE OLDER PERSONS

Environmental suggestions during assessment of the older adults

Provide adequate space, especially if client uses mobility aids

Minimize noise and distractions Set a comfortable, warm temperature with no

drafts. Use diffuse lighting. Avoid glossy or highly polished surfaces.

Place client in a comfortable position

Maintain proximity to the bathroomKeep water and other preferred

fluids availableProvide a place to hang or store

garments and belongingsMaintain absolute privacy

Plan the assessment: consider client status

Be patient, relaxed and unhurried.Allow client plenty of time to

respond to questions and directions. Maximize use of silence.

Be alert to signs of increasing fatigue.

Conduct assessment during client’s peak energy time.

THE HEALTH HISTORYThe first phase of a comprehensive,

nursing-focused health assessment, provides a subjective account of the older adults’ current and past health.

The nursing history should include assessment of functional, cognitive, affective, and social well-being.

The interviewer should adapt the styles and techniques of interview in the process.

THE INTERVIEWERFactors to consider during nurse-client communication during assessment

Attitude of nurseMyths and Stereotypes about older

peopleNurse’s own anxiety and fear of

personal aging

Guide to an effective interview

State reason for the interview

Let client accomplish a pre interview form

A goal-directed interview process

Setting of time limit

Secure permission to take down notes

Observe most effective and comfortable distance and position, and personal space for the session

Appropriate use of touchTake advantage of

opportunities such as meal time, game, hobby, and other social activity.

THE CLIENT There are factors the nurse should

consider while interviewing an older adult such as:

Sensory-perceptual deficits Anxiety Reduced energy level Pain Multiple and interrelated health problems The tendency to reminisce

THE HEALTH HISTORY FORMAT

Client Profile/ Biographic dataFamily ProfileOccupational ProfileLiving Environment profileRecreation/Leisure ProfileResources/Support systems used

THE HEALTH HISTORY FORMAT

Description of typical day Present health status Medications Immunization and health Screening

Status Allergies Nutrition Past Health Status Family History Review of Systems

SYMPTOM ANALYSIS FACTORS

Dimensions of a SymptomLocationQualityQuantityTimingSettingAggravating or Alleviating

factorsAssociated symptoms

THE PHYSICAL EXAMINATION APPROACH AND SEQUENCE

Should be systematic and deliberateDetermine client strengths and

capabilities; disabilities and limitations

Verify and gain objective supportGather objective data not previously

known

GENERAL GUIDELINES

Recognition of no previous experience with the nurse conducting physical examination by the adult

Be alert on the clients energy levelRespect the client’s modestyKeep the client comfortably drapedSequence examination to keep

position changes to a minimum

Develop an efficient sequence for examination that minimizes nurse and client movement

Ensure comfort for the clientWarn of any discomfort that may occur.

Be gentleProbe painful areas lastShare findings with the client when

possibleTake advantage of teachable momentsDevelop a standard format on which to

note selected findings.

EQUIPMENT AND SKILLS

Check proper function and readiness of all equipment

Place equipment within reachUse of Inspection, Auscultation,

Palpation, and Percussion.

ADDITIONAL ASSESSMENT MEASURES

Functional Status Assessment – refers to the measurement of the older adults’ ability to perform basic self-care tasks, or ADLs, and task that require more complex activities for independent living referred to as IADLs.

KATZ Index of ADLs –

Determines results of treatments and the prognosis in older and chronically ill people.

Barthel Index – tool for measuring functional status, rates self-care abilities in the areas of feeding, moving toileting, bathing, walking, propelling a wheelchair, using stairs, dressing and bowel and bladder control

Lawton and Brody’s IADLs – a range of activities more complex than KATZ and Barthel. Usage of telephone, shopping, preparing food, housekeeping, laundry, meds, transporting and finances.

Cognitive/Affective Assessmentassesses level of cognitive function

and the effect of the assessed degree of impairment on functional ability

Short Portable Mental Status Questionnaire (SPMSQ) –

used to detect the presence and degree of intellectual impairment to assess orientation, memory in relation to self-care ability, remote memory and mathability.

MiniMental State Examination – tests the cognitive aspects of mental function: orientation, registration, attention, and calculation, recall and language

Mini-Cog - an instrument that combines a simple test of memory with a clock drawing test.

Geriatric Depression Scale - a score of five (5) or more may indicate depression

Social Assessment – (1) Social function is correlated with physical and mental function, (2) an individual’s social well-being can positively affect his or her ability to cope with the physical impairments and ability to remain independent, and (3) a satisfactory level of social function is a significant outcome in and of itself.

Family APGAR – Stands for: Adaptation, Partnership, Growth, Affection and Resolve.

Older Adult Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire - a social resource scale, one of the better-known measures of general social function for older adults

Thank you!!