Nursing Care of the Older Adult

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Nursing Care of the Older Adult Standards of Care Developed by American Nurses Association (ANA) Purposes:  Evaluate and guide practice  Set goals for quality care delivery to the older person Standards of clinical gerontological nursing care Standards of professional gerontological nursing performance Standards of Clinical Gerontological Nursing Care Standard I: Assessment Standard II: Diagnosis Standard III: Outcome identification Standard IV: Planning Standard V: Implementation Standard VI: Evaluation Standards of Professional Gerontological Nursing Performance Standard I: Quality care Standard II: Performance appraisal Standard III: Education Standard IV: Collegiality Standard V: Ethics Standards of Professional Gerontological Nursing Performance Standard VI: Collaboration Standard VII: Research Standard VIII: Resource Utilization

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Influences • Decrease in metabolically active cells • Increase in adipose tissue weight = reduction in lean body mass Energy requirement Determinants  Number of calories necessary for basal metabolism  Number of calories needed for muscular activity  Number of calories necessary for digestion and absorption of food Formula  Harris – Benedict Equation WOMEN: BEE = 65.1 + [9.6 x wt (kg)} + [1.8 X ht (cm)] – [4.7 x age (yrs)] MEN: BEE = 66.5 + [13.8 x wt (kg)} + [5 X ht (cm)] – [6.8 x age (yrs)]  Physical Activity/Illness Provision PA = BEE X ACTIVITY FACTOR IP = BEE X ILLNESS PROVISION  Thermic effect of food TEF = BMR X 10% + BMR Energy requirement = PA or IP + TEF +

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BEE  Energy requirement ACTIVITY LEVEL ACTIVITY

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Ethical Aspects in the care of the older person Ethical dilemma Choice between 2 equally undesirable alternatives ◦ Decision for the best health care treatment to benefit the older person ◦ Meeting the older person’s need for independence, freedom and respect and availability of health care regardless of condition or age Traditional ethical theories Deontology (Rule – oriented theory) ◦ Categorical imperative: a rule that should be applied to all people in similar circumstances when rendering an ethical decision ◦ Prioritize ethical principles of  Autonomy  Beneficence  Nonmaleficence  Justice Traditional ethical theories Utilitarianism (Goal oriented theory) ◦ In all situations, one must morally do the most good for the most people  “The end justifies the means”  Consequences of actions assume primary significance for the most appropriate action Steps of the Ethical decision Making Process Related to the Nursing Process Assessment ◦ What are the medical facts? ◦ What are the social facts? ◦ What are the client’s wishes? ◦ What values are in conflict? Planning ◦ Determine the desired outcome of the treatment ◦ Identify the decision makers ◦ List and rank options Implementation ◦ Make a decision based on the above steps ◦ Act to implement the decision Evaluation ◦ Maintain an ethical reflection on the decision ◦ Establish criteria for revision of goal or decision

CALORIC EXPENDITURE (kcal/kg/hr) FEMALE 1.0 1.2 MALE 1.1 1.3

BED REST SEDENTARY/VERY LIGHT Male: Teacher, Barber, Executive, Businessmen, Shoemaker, Priest, Retired personnel, Landlord, Peon, Postman Female: Teacher, Tailor, Executive, Businesswoman, Housewife, Nurse Seated and standing activities, painting trades, laboratory work, typing, playing musical instruments, sewing, ironing

ACTIVITY

CALORIC EXPENDITURE (kcal/kg/hr) FEMALE MALE

LIGHT Walking on level (2.5-3 mph), tailoring, pressing, garage work, electrical trades, carpentry, restaurant trades, cannery workers, washing clothes, shopping with light load, golf, sailing, table tennis, volleyball MODERATE Male: Fisherman, Basket-maker, Potter, Goldsmith, Agricultural laborer, Mason, Rickshaw-puller, Electrician, Fitter, Turner, Welder, Industrial Laborer, Weaver, Driver Female: Maid servant, Coolie, Basket-maker, Weaver, Agricultural laborer Auto and truck driving, walking (3.5-4 mph), plastering, weeding and hoeing, loading and stacking bales, scrubbing floors, shopping with heavy load, cycling, skiing, tennis, dancing HEAVY/ VIGOROUS Male: Stone-cutter, Blacksmith, Mine-worker, Woodcutter Female: stonecutter Walking with load uphill, tree felling, work with pick and shovel, basketball, swimming, climbing, football

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1.6

1.6

1.7

Nursing Interventions for Specific Problems and Supportive Care for the Elderly  1. 2. 3. 4.  NUTRITIONAL CONSIDERATIONS Energy requirement Macro and micro nutrients Factors influencing nutritional status of older adults Nutrition programs for older adults Energy Requirement  Normal changes with aging  Caloric reduction: • 10% for 51 – 75 y.o • 20 – 25% for more than 75 y.o

1.9

2.1

Strenuous, Exceptional, Special conditions, Severe conditions, Pregnancy, Diabetes mellitus and Hypertension

2.2

2.4

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ILLNESS PROVISIONS ILLNESS

STRESS FACTOR KCAL / KG FEMALE MALE 1.0 1.1 1.2 1.3 1.2 1.4 1.7 2.0

No illness / non-stress Convalescence, mild malnutrition, postoperative (no complication) Mild illness, non-catabolic Confined to bed Ambulatory / out of bed Infections and stress, catabolic Mild Moderate Severe, hypercatabolic Sepsis Burns < 20% BSA 20-40% BSA > 40% BSA Severe Fracture, long bone

1.0 1.1 1.2 1.3 1.1 1.3 1.5 1.8

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1.2 1.5 1.8 2.1

1.4 1.7 2.0 2.3

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Respiratory / Renal failure

1.4

1.5

COPD

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1.6

Cancer with chemotherapy or radiation; cardiac cachexia

1.5

1.6

Surgery, Minor, Elective Major

1.1 1.2

1.2 1.3

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Trauma Skeletal, blunt Multiple, head injury

1.3 1.5

1.4 1.6

 Alternative source of energy  Feeling of satiety  Improve the flavor of food Desirable intake: 30% or less of total energy intake  SF: 10 – 15% of total energy intake  Cholesterol: 300 mg or less per day Carbohydrates Importance  Prevent tissue protein breakdown  Maintain normal blood glucose level  Make up calorie deficits Requirement: 50 – 58% of daily caloric intake  Simple sweets: no more than 10%  Complex CHO: remainder of the 50 – 50% Problems  Diabetes mellitus  Pancreatic malfunction  Decreased cellular sensitivity to insulin  Glucose intolerance  Lactose intolerance Fiber Importance: Bowel maintenance RDA: 25 – 25 g/day Suggestions to increase dietary fiber  Eat fresh fruits and vegetables  Eat some skin of fruits and vegetables  Use whole grain and cereals  Eat unbattered air popped corn Vitamins Importance  Regulate metabolism  Help convert fat and CHO into energy  Assist in forming bones and tissues Fat soluble vitamins Vitamin A  Importance: maintain skin and MM; protect against night blindness  RDA: M = 1,000 RE (5,000 IU); F = 800 RE (4,000 IU)  Considerations: note frequent intake of mineral oil as laxative Vitamin D  Importance: aid in the absorption of Ca and P for bone formation  RDA: 400 IU  Considerations: people exposed to sunlight need no supplementation; intake of food fortified with vitamin D Vitamin E (Tocopherol)  Importance: antioxidant; maintain the immune system; reduce risk of colon cancer; retard atherosclerosis  RDA: F = 8mg TE; M = 10mg TE Vitamin K  Importance: prothrombin function and blood clotting  Requirement: 1g/kgBW  Considerations: antibiotics and mineral oil as laxative interfere with vit. K absorption Water - soluble vitamins  Thiamin  Importance: change glucose to energy to supply the brain and nerves; essential for fat and protein metabolism  RDA: 0.5mg /1000 calories  Riboflavin  Importance: energy metabolism  RDA: 0.6mg /1000 calories  Considerations: deficiency associated with high carbohydrate diet lacking in animal protein milk and vegetables 

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Macro and Micro nutrients Protein  12 – 14% of daily caloric requirement  High quality protein: meat and vegetables  RDA: 0.8 g/kg BW  Deficiencies  hunger  edema  nutritional liver disease  pellagra  nutritional macrocytic anemia Fats Importance  Ensure presence of essential fatty acids  Allow adequate intake and utilization of fat – soluble vitamins  Serve as lubricant

Niacin 

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 Pyridoxine  Importance: amino acid metabolism and protein synthesis  RDA: F = 1.6mg; M = 2mg  Considerations: poorly absorbed in persons with liver disease; deficient in people with uremia and GI disease; people taking Ldopa should avoid taking pyridoxine supplements Cyanocobalamine

Importance: release of energy from CHO; synthesize fats and protein RDA: F = 14mg NE; M = 16mg NE

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Importance: maintain healthy RBC and myelin sheath RDA: 2 µg Considerations: give via injection for persons deficient with IF and free HCl

insulin may lead to rapid potassium shift that can lead to cardiac failure  Iodine    Importance: synthesis of thyroid hormones RDA: 150 µg Consideration: adding iodine to table salt had reduced the incidence of endemic goiter Importance: component of myoglobin; utilized for AA, hormone and NT synthesis; production of healthy RBC RDA: 10mg for aged 60 and above Consideration: meat iron is efficiently absorbed than those form vegetables; absorption can be enhanced by the presence of vitamin C Conditions that need increase iron  Bleeding hemorrhoids  GI lesions Importance: component of enzymes and proteins with catalytic and structural functions; synthesis of DNA, RNA and protein; stabilize cell membranes; essential for growth and cell division, reproduction, taste acuity, wound healing and normal immune response RDA: M = 15mg; F = 12mg Consideration: decrease absorption occurs with aging; stress increase excretion of zinc in the urine; medication (diuretics, antacids, laxatives) increase excretion and decrease absorption of zinc; vegetables have lower levels of zinc

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Importance: metabolism of AA and hemoglobin synthesis  RDA: M = 200 µg; F = 180 µg  Considerations: anticonvulsant drugs and alcohol produce transitory malabsorption of folate Ascorbic acid  Importance: promote growth and repair of tissues; aids ion bone formation and repair  RDA: 60 mg  Considerations: some clients develop aversion to acidic foods thus restricts vitamin C intake

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Iron 

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Minerals  Compose approximately 4 – 5% of body weight  Roles  Regulate metabolism via enzymes  Maintain A-B balance and osmotic pressure  Facilitate membrane transfer of essential compounds  Maintain nerve and muscular irritability  Building components of body tissues and growth process  Calcium  Importance: proper bone mineralization; maintain proper blood clotting, cell wall permeability, muscle contraction, nerve transmission and cardiac function  RDA: 1,200mg ( 60 y.o and above) @ 1:1 ratio with phosphorus  Consideration: Vitamin D must be present for Ca absorption  Calcium  Age – related changes needing increase calcium • Menopause: osteoporosis • Illness • Drug – nutrient interaction • Low exposure to sunlight • Lactose deficiency • Decrease physical activity  Phosphorus  Importance: proper bone mineralization; metabolism of CHO, fats and protein; maintain A-B balance  RDA: 800 mg @ 1:1 ratio with Ca  Consideration: older adults taking large amounts of antacid may have increase excretion of Phosphorus Magnesium  Importance: metabolism; regulate nerve and muscle function  RDA: 350mg  Consideration: severe loss of body fluids, malabsorption and liver disease may lead to deficiency Sodium  Importance: maintain normal osmotic pressure and fluid balance  AI: 1,100 – 3,300mg/day  Consideration: 10 – 30% reduction for people with hypertension and sodium sensitivity Potassium  Importance: enzyme reaction within cells  AI: 1,100 – 3,300mg/day  Consideration: deficiencies occur in chronic alcoholism; malnutrition and conditions that interfere with appetite and absorption; diuretic use; rapid infusions of glucose and

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Zinc 

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Water 

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Importance: maintain fluid balance  Body water: decrease with age  Young men: 60% of body weight; older men: 52% of BW; Young women: 50% of BW; older women: 45% of BW  Water loss: 2,400ml/day RDI: 6 – 8 8oz glasses of water per day Considerations: older adults often find liquids more acceptable in soups, fruit juices, milk products, soft drinks, tea and coffee.  Clients with difficulty in swallowing: thin liquids with thickeners, water, gelatin, fruit ices, yogurt, custards, pudding RDI: 6 – 8 8oz glasses of water per day Considerations: older adults often find liquids more acceptable in soups, fruit juices, milk products, soft drinks, tea and coffee.  Clients with difficulty in swallowing: thin liquids with thickeners, water, gelatin, fruit ices, yogurt, custards, pudding

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Factors Influencing the Nutritional Status of the Older Adult Socioeconomic Factors  Nutritional imbalance  Risk factors:  Limited income + age = poor nutritional status  Inflation: limited purchasing power • Limited income + inflation = decrease meat, increase CHO containing food → high calorie less nutrient density Socioeconomic Factors  Nutritional imbalance  Risk factors:  Lack of transportation  Separation from family members, friends, community and familiar surroundings  Lack of nutrition information due to little or no formal education Socioeconomic Factors  Nursing intervention  Home visit to evaluate client’s ability to purchase a balanced diet  Discussion of food costs, preparation, leftover recycling and information on meals

   Psychological factors Loneliness Boredom Anxiety Fear Bereavement General unhappiness

Routine recording of food intake and daily weighing Assess for food faddism: very expensive miracle cure

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Isolation And Depression

Refusing to eat = malnutritio n Overeating =obesity

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Psychological factors  Failure to thrive  Sx: dehydration; impaired cognition; dementia; impaired ambulation; difficulty with at least 2 ADL  Causes: neglect; behavioral problems; family stress; substance abuse  Intervention: psychosocial and spiritual interventions Cultural - Religious factors  Predisposing causes: familiar food patterns; distinctive ethnic, regional, racial characteristics  Interventions  In – depth analysis of client’s dietary habits  Ethnic or racial affirmation through suggesting the use of traditional foods  Encourage good food habits of client’s cultural group with gradual changes in client’s food habits  Factors Influencing the Nutritional Status of the Older Adult Physiological factors  Normal changes in aging  Chronic diseases: alter food intake  Obesity  Cardiovascular diseases: heart attack, stroke  Diabetes mellitus  Osteoporosis  Hypertension  Dysphagia  Feeding issues: dietary restrictions as part of the management of the condition  Factors Influencing the Nutritional Status of the Older Adult  Interventions  Environment free of odors, clean and orderly with appropriate ventilation and temperature  Comfortable, upright position for client  Assess client's ability to swallow before feeding  Sit across from the client with client looking straight ahead. Introduce food straight to the mouth  Factors Influencing the Nutritional Status of the Older Adult  Test food temperature  Start by offering liquids or thin soups served in a container with covered lid  Identify each food as it is given  Ask client to smell food  Do not mix food together  Allow time for eating at a slow pace  Factors Influencing the Nutritional Status of the Older Adult  Blot the mouth, do not wipe  Have person use upper lip to scrape food form utensil  Place food well into the client’s mouth to avoid tongue thrust  Keep food moist  Observe which texture are easier to chew and swallow  Factors Influencing the Nutritional Status of the Older Adult  Place food on the unaffected side, if the person is paralyzed  Encourage person to think swallow  Allow for and accept feelings of frustration, anger and embarrassment Nutrition Program for Older Adults

Meals on wheels program  Provides hot meals that are delivered to older adults unable to leave home  Provided at the community level  Cost based on the ability to pay of the older adult Food stamp program  Allows a person on a very limited budget to purchase more food  Provision of basic nutrition to low income families; information on wise shopping, basic food needs, and food preparation techniques Guide for Menu Planning  Serve meals on regular schedule  Include variety of food  Serve smaller amounts of food more frequently  Be aware of new trends in nutrition education  Make older adults aware that money spent on nutritional food is money well spent  Nutrition Program for Older Adults  Recognize food and drug interaction  Prepare and serve food attractively  Increase fluid intake  Increase fibrous food for proper elimination  Recognize social, economic, cultural and religious factors  Season food to stimulate taste buds  Nutrition Program for Older Adults  Use PUFA (oils and margarine)  Select complex CHO  Learn to identify intolerances  Use meat substitutes such as cheese, dried beans and peanut butter  Use various forms of milk  Serve fresh fruits and vegetables  Serve whole grain or enriched breads and cereals  Follow instructions for therapeutic diets  Check menu against a daily food guide, suggested serving or food guide pyramid

Nursing Interventions for Specific Problems and Supportive Care for the Elderly Medication Management 1. Polypharmacy 2. Pharmacodynamics 3. Pharmacokinetics 4. Drug Interactions 5. Generic Medications 6. Medication Administration 7. Nursing Interventions in Client Education 8. Effects of Medications commonly used by older adults 9. Geriatric psychopharmacology Polypharmacy o Concurrent use of multiple prescription drugs and OTC drugs o Consequences  Adverse drug events  Drug – drug interaction  Drug – disease interaction  Duplication of therapy  Decrease in quality of life  Unnecessary financial and societal stress o Medications associated with adverse reactions in the older adults  Digoxin heart block, cardiac arrhythmias, anorexia, vision changes (blurred), confusion and depression  Calcium channel blockers Increased mortality, gastrointestinal bleeding, and cancer  Sympathomimetics/antihistamines hallucinations, convulsions, CNS depression, and death  NSAID GI: heartburn, constipation, abdominal pain, nausea, diarrhea, and vomiting CV: raise blood pressure and cause retention of salt and water. CNS: Headaches, dizziness and drowsiness Skin: bullous drug eruptions and Stevens Johnson syndrome  Benzodiazepines confusion, night wandering, amnesia, ataxia (loss of balance), hangover effects and "pseudodementia"  Antidepressants orthostatic hypotension, sedation, cardiac toxicity, and anticholinergic reactions  Beta blockers Cold sensitivity, dizziness, COPD, urge incontinence  Diuretics Hypotension, dizziness, light headedness, electrolyte imbalance  Corticosteroids Mania, depression, psychosis, delirium  Theophylline

Seizure; diarrhea, irritability, restlessness, fine skeletal muscle tremors, and transient diuresis  Neuroleptics anticholinergic reactions, parkinsonian events, tardive dyskinesia, orthostatic hypotension, cardiac conduction disturbances, reduced bone mineral density, sedation, and cognitive slowing Pharmacodynamics o Aging – related changes o Decreased adrenergic receptor response → less pronounced bradycardia (beta – adrenergic blockers) or less tachycardia (isoproterenol) o Increase receptor response with BZD, opiates, warfarin → BZD with increase sedation; opiates with increase analgesia; warfarin with increase anticoagulant effect o Nursing interventions o Vigilance concerning the enhanced efficacy or diminished activity of medications when given to the elderly patient Pharmacokinetics o Drug absorption Aging effects: decrease absorption Decrease in HCl production 30% decrease in mucosal surface area of the S.I → decrease absorption 40% reduction of blood flow in the SI o Drug distribution Aging effects on the body Decrease lean body mass Relative decrease in total body water Reduced serum albumin Increase in body fat Aging effects on the drug Increase digoxin level related to decrease water and lean body mass Fat soluble drugs will have increased half life Higher concentrations of water soluble drugs due to reduction in body water o Protein binding Aging effects on the body Decrease protein binding sites resulting form chronic illnesses in the elderly → increase in free biologically active drugs Deminished blood flow → decrease in drug delivery to various sites o Hepatic metabolism Aging effects on the body Decline in hepatic blood flow → affect production of active metabolites o Renal elimination Aging effects Decrease in GFR and renal tubular secretion → Reduced rate of drug elimination Drug Interactions o Drug – Drug interaction o Synergistic or antagonistic effect due to reduction in drug excretion and metabolism Drug – disease interaction o Drug used to treat one disease may worsen the other disease and possibly trigger another medical problem o Example: timolol (glaucoma) → bradycardia; heartblock o Drug – Nutrient interaction o Effects o Suppression or stimulation of appetite o Altered nutrient digestion and absorption o Altered metabolism or utilization of nutrient o Altered nutrient excretion o Risk factors o Pathophysiological changes related with aging o Multiple chronic diseases o Endocrine dysfunction o Alcoholism o Ingestion of restricted diets Generic drug o Substitution o Influences o Cost of branded drug o Increase in adverse effects and change in efficacy experienced by the elderly o Nursing intervention o Nurses should be aware when the prescription had been filled with generic drug o Advocate for client by consulting with the physician o Observe for side effects or lack of efficacy of the drug Medication administration o

Problems of self administration o Failure to inform the client/failure to understand how to take the drug o Client forgetfulness o Multiple prescriptions o OTC taken together with prescription drugs o Failure to take entire prescription o Obtaining drugs from more than one physician Nursing Interventions in client Education o Vigilance o Constant assessment of the client’s response to the drug or adverse or toxic effects coupled with knowledge in pharmacogeriatrics o Accountability o To all aspects of medication administration taking medico-legal issues in consideration o Responsibility o Teach about medications, including self administration techniques and behaviors to remove any barriers to adherence Effects of Medications Commonly Used by the Older Person

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Drug

Effect

Cardiotonic drugs

Digitalis toxicity

Antihypertensive agents Diuretics to treat hypertension

Orthostatic hypotension

Increase excretion of some ions

Beta adrenergic blocking agents

CNS depression, confusion, symptomatic bradycardia and development of heart failure

ACE inhibitor

Effect hypertension control and reduce left ventricular hypertrophy

Drug

Effect

Ca channel blockers Analgesic

Heart block, bradydysrhythmia, flushing, headache, tachycardia, peripheral edema Tinnitus and hearing loss (acetaminophen and salicylates); gastropathy (NSAID); sedation and decrease in concentration and ability to drive (Opioid)

Drugs

Effects

Interventions

Antipsychotics

Significant toxicity with a very low dose

Thorough evaluation for the necessity of drug administration Gradual dose reduction Drug holiday Side effect monitoring Behavioral programming Close monitoring for drug effect

Antidepressants

EKG changes, orthostatic hypotension (tricyclic)

Drugs

Effects

Interventions

Antianxiety agents, sedatives and hyptnotics Antihistamine

Withdrawal symptoms on discontinuation Cognitive changes

Choose medications with chorter half life, less lipophilic Watch for fall

Practitioners – Physicians – Nurses – Physician assistants – Social workers – Dietitians – Pharmacists • Primary Care Centers Hospital based Advantages –

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–    Principles In The Care Of The Older Person Principles of Gerontological Nursing Commitment to relationship-centered care  Older person as part of complex relationships  Relationships impact the person’s care processes Commitment to negotiating care decisions  Older person has the right to informed choices  the older person's choices are respected Principles of Gerontological Nursing Promoting dignity and respect  Dignity and respect maintained regardless of setting Maximizing potential  Caring events as therapeutic activities  empower the older person to live a life that reflects individuality Principles of Gerontological Nursing Commitment to an enabling environment  Promoting a positive work culture together with supportive physical and organizational environment  Conveys a sense of hope and achievement to the older person Establishing equity of access  Same access to health services for the older person same as the other ages without discrimination Principles of Gerontological Nursing Commitment to developing innovative practice  Promote evidenced-based gerontological nursing practice Consistency of vision  Shared care philosophy among gerontological nurses Principles of Gerontological Nursing Commitment to teamwork  Nurse work as part of the care team  collective effort towards attaining goals negotiated with the older person The value of reciprocity  Recognize the value of mutual respect between all parties involved in the care of the older person – –

Can expand services into the unserved and the underserved areas Provide comprehensive services for older adults Provide expertise to other programs for older adults provide advantage for strengthening continuum of care strategy

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• Primary Care Centers Hospital Based Services offered – – – – – Outpatient services Physician services Diagnostic testing of all types Emergency care if needed Educational programs on wellness and health promotion

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Community Resources for Care of the Older Persons Settings of care Primary care centers – Hospital based – Managed services organization – Community nursing organization Hospital outpatient care and services – Wound healing and hyperbaric centers – Preventive outpatient services – Cardiac rehabilitation services – Sport medicine and rehabilitation outpatient services – Incontinence program – Pain clinic centers – Sleep laboratories Settings of care Ambulatory care centers – Mobile health care programs – Membership program – Caregiver support – Partial hospitalization Day care program – Case management – PACE program Community services Primary Care Centers Purpose – Deliver care to Medicare enrollees

• Primary Care Centers Managed service organizations • Private clinics or private practice • Establish links with hospitals and health care providers to deliver the best care possible for the older person • Manage services for the older person • Primary Care Centers Community nursing organizations: Visiting nurse services • Stress health promotion and disease prevention • Provide nurse – managed care in a variety of setting – Physical therapy – Speech – language pathology – Occupational therapy – Skilled nursing care – Home health aides – Social work – Outpatient therapies • Hospital outpatient care and services Wound healing and hyperbaric centers • Deliver 100% to promote RBC growth and promote wound healing; remove CO2 and N2 from the circulatory system; destroy oxygen sensitive bacteria • Indication: – Primary therapy: arterial gas embolism; decompression sickness; exceptional blood loss anemia; severe carbon monoxide poisoning • Hospital outpatient care and services Wound healing and hyperbaric centers • Indication: – Adjunctive therapy: clostridial myonecrosis, compromised skin graft and flaps; osteoradionecrosis prevention; acute traumatic ischemia; refractory osteomyelitis, selected problem wounds (chronic wounds: Diabetic foot and leg ulcers); radiation – induced soft tissue injury; necrotizing fascitis; thermal burns • Hospital outpatient care and services Preventive outpatient services • Health screening and education – Diabetes and asthma education programs » Diabetes management: patient and caregiver education » Educators: certified diabetes nurse educators; registered

dietitians and medical diabetitians • Hospital outpatient care and services Cardiac rehabilitation services • Process by which patient and family systems are restored optimal physical, medical, psychological and economic status • Emphasized the client’s contribution towards recovery: permanent life style changes • Goals – Preservation of function – Strengthening and coordination to provide mobility and self sufficiency • Hospital outpatient care and services Sport medicine and rehabilitation outpatient services • Goal: improve human functioning through comprehensive therapy • Providers: PT, OT, speech-language pathologist, nutritionist, athletic trainers • Focus: ability to bathe, speak, feed, dress, groom oneself, transfer and ambulate • Hospital outpatient care and services Incontinence program • Cause of incontinence: pelvic floor muscle weakness • Conservative treatment program that uses therapeutic exercises, biofeedback, electrical muscle stimulation, extensive client evaluation • Hospital outpatient care and services Pain clinic/centers • Indication: – clients whose pains or symptoms may not be consistent with physical findings – Pain caused progressive deterioration in function at work, home and social activities and show inability to cope emotionally – Pain experience is accompanied by feelings of anger, hostility and depression • Hospital outpatient care and services Sleep laboratories • Causes of sleep awakenings in the older person: – Less deep sleep → more night time awakenings; early morning awakenings – Higher incidence of indigestion, arthritic pains, restless leg syndrome, sleep apnea and circulatory problems – Decline in bladder capacity • Determine causes of awakenings and sleep problems through the sleep studies and polysomnography use • Ambulatory Care Centers • Mobile health care programs – Advantages: reach individuals that who would normally not seek health care services or lack access because of transportation difficulties or other factors – Services offered • Health education and screening • Immunizations: influenza and pneumonia • Respiratory therapy, physical therapy, occupational therapy • Dermatology screening • Blood glucose monitoring • Cholesterol screening • Health fairs (BP screening) • Osteoporosis screening • Mammography • Ambulatory Care Centers • Membership programs – Goal: support positive attitude towards living a healthier life – Offer • discounted services and products: pharmaceuticals, medical supplies, optical and dental services • Travel discounts and group trips that are socially beneficial • Workshops on health topics • •

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Older adult education: medicare options, health insurance, living wills, powers of attorney and financial planning Ambulatory Care Centers Caregiver support group – Offer family education and support on care management • Education – Aging process – Effective communication with sensory impaired individuals – Community resources management – Burn out prevention and maintain caregiver health • Emotional support and counseling – Sharing of experiences – Realize own situation and difficulties are not unique – Assist in decision-making and facing difficult issues Ambulatory Care Centers Partial Hospitalization Day Program – Indication: older adults experiencing anxiety, depression or other mental health problems – Services offered • Intensive outpatient psychiatric/mental health program under the direction of a geriatric psychiatrist – Combination of group and individual therapy – Medication management and monitoring • Half day to full day care with meals and transportation services Ambulatory Care Centers Case management program – Care coordination program – Provide a continuum of care form the hospital to the community – Providers • Nurse case managers: – Responsibilities: » care and monitor high risk older adults by coordinating medical and social services » provide client and family information on disease and medication management, treatment options and community resources Ambulatory Care Centers PACE Programs (Program of All-inclusive Care for the Elderly) – Provide care for older adults that are at risk for nursing facility placement – Services offered • Assessment of participant’s needs • Develop treatment plans • Provide care • Identification of changes in client’s condition to prevent deterioration and provide plan modification Community Services Information and Assistance – Provide information to older adults about public, voluntary and private services availability Client assessment – Elicits information regarding the need for services and eligibility requirements Care management – Provides review and analysis of information and data regarding the individual’s psychological, social and health challenges and problems – Identification of functional abilities and needed support services Community Services Transportation – Purpose • Enriches the individual’s life by expanding opportunities for social interaction and community involvement and supports individual’s capacity for independent living – Services offered

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• Community Services Employment services – Secure meaningful employment and ensure supplementing income for the elderly Senior center program – Serve as source of information and referral – Linkage in the community to combat isolation – Arrange variety of recreation and social activities – Services offered • Meals, travel and transportation, education, exercises, health assessment, and counseling Community Services Senior housing – Rental apartments, group residence, hotel style housing designed with features that enhance functional abilities and promote secure living environment – Goal: allow the elderly for independent living Alternative community-based living facilities – Types: adult foster care, board and care homes, residential care facilities, assisted living – Goals: • Bridge the gap between totally independent living and nursing facility care • Enhance independence of the older individual and delay the need for intense personal care Community Services Homemakers – Assist with household tasks: range from shopping to food preparation Chore services – Assist with more heavy task and home maintenance: floor and window washing, minor home repairs, yard work and others Home health services – Skilled nursing care, health monitoring and evaluation of medication administration, physical and other types of therapy, psychological counseling and health care education Community Services Home attendant or aide services – Provide assistance with ADL: feeding, bathing, walking – Provided by individuals with special training in providing special care and services and supervised by a nurse or a physician Respite care – Provide relief for caregivers form caregiving responsibilities to prevent physical health problems, emotional problems and social isolation Community Services Friendly visiting – Offers social contact, human interaction and assurance to the elderly Emergency response system – An electronic device is connected to the client that would alert the local fire department, hospital and other health facility or social service agency of the individual’s status

Financial assistance to transportation for the elderly Special transportation services

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Insufficient time spent with clients Confusion resulting from conflicting recommendations by various health experts or panels  Health provider’s concerns over risk vs benefit of screening procedures  Health provider’s concern about the cost effectiveness or preventive efforts  Medical school focus on illness and disease Secondary Level of Prevention Early detection and treatment of diseases Areas of focus  Health screening  Counseling interventions  Immunization programs  Chemoprophylactic regimens Health Screening Purpose  Detect diseases when they are still treatable and possibly curable Health Screening Tertiary Level of Prevention intervention done after the disease or condition had been diagnosed and treated an attempt to return the client in an optimum level of health and wellness despite the condition or disease Activities  Rehabilitation  Patient education Tertiary Level of Prevention Patient education  Preparing clients for discharge  Medication regimen: what, purpose, amount, when, how, side and adverse effects, effect on quality of life  Dietary adaptations based on condition  Mobility and safety factors: use of assistive devices; timing and type of exercises  Treatment and care required/needed based on the client’s current condition and ongoing medical diagnosis  All personal ADL Tertiary Level of Prevention Patient education  How to teach geriatric clients (Basic assumptions to keep in mind)  Maintain a climate of respect  Involve collaboration among students, teachers and other resources  Help learner’s achieve empowerment and self-direction  Capitalize on learner’s experience  Foster participation  Foster critical and reflective thinking  Involve learner for action  Pose problem-solving opportunities Tertiary Level of Prevention Patient education  Barriers to Older adults learning  Myth: people past retirement age are too old to learn  Personal attitudes about life-long learning  Physiological changes with aging: vision and hearing  Low self-esteem, depression, chronic illness and altered mental state

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Levels of Care of Gerontological Nursing Primary Level of Prevention Measures to prevent an illness or disease from occurring Health promotion  Encouragement of healthy habits and lifestyles known to maximize one’s quality of life  Immunization  Proper nutrition: low fat diet  Regular fluoride dental treatments  Regular exercise Primary Level of Prevention Purposes  Decrease risky behavior to avoid unnecessary disability  Promote independence Areas for health promotion  Maximizing quality of life  Emotional and spiritual health  Holistic health Primary Level of Prevention Barriers to health promotion  Inadequate reimbursement for preventive medicine practice  Fragmentation of health care delivery system

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Nursing Interventions for Specific Problems and Supportive Care for the Elderly Assistive technology devices Mechanical aids that substitute for or enhance the function of some physical or mental ability that is impaired Purposes – bridge the gap between an older person’s declining capabilities and the unchanging environmental demands of home and community – enable independent performance, increase safety, reduce risk of injury, improve balance and mobility, improve communication, and limit complications of an illness or disability – Guidelines for Introducing Technology, and Teaching the Elderly About Its Use The use of technology must be perceived as needed and meaningful, and must be linked to the lifestyle of the person. Cautions and disbelief in one’s capability may be an obstacle in accepting new technology and must be considered when creating the learning environment.

A generous amount of time as well as repeated short training sessions should be allowed. • Guidelines for Introducing Technology, and Teaching the Elderly About Its Use • More stress should be placed on the practical application of the device than on its technical features. • Only selective, central facts should be presented. • Mnemonics and cues will favorably affect self-efficacy in handling new products. • Training sessions should be held in the home or natural meeting places of the elderly. • Guidelines for Introducing Technology, and Teaching the Elderly About Its Use • The instructor should be well-known by the elderly or introduced well in advance of the training. • The attitudes of the instructors toward the aged must be positive and realistic. • Common Applications of Assistive Technology 1) position and mobility, 2) environmental access and control, 3) self-care, 4) sensory impairment, 5) Social interaction and recreation, and 6) Computer based technology • Position and Mobility • Positioning equipments – walkers, floor sitters, chair inserts, wheelchairs, straps, traps, and standing aids. • Mobility equipments – self-propelled walkers, manual or powered wheelchairs, and powered recreational vehicles like bikes and scooters. • Environmental access and control • Environmental access – Ramps and door openers to enter; Braille directions for visually impaired; low payphones and elevator buttons for people of short stature and wheelchair bound • Environmental control – remote control switches and special adaptations of on/off switches to make them accessible; robotic arms; control modules – Self care • Devices – robotics, electric feeders, adapted utensils, specially designed toilet seats, and aids for tooth brushing, washing, dressing, and grooming, emergency response system (ERS), remote health monitoring devices, – Sensory Impairment • Augmented and alternative communication (AAC) – to all forms of communication that enhance or supplement speech and writing either temporarily or permanently – Devices: touch screen, keyboard, and infrared head pointers – Social Interaction and Recreation • Devices – drawing software, computer games, computer simulations, painting with a head or mouth wand, and adapted puzzles • Computer-Based Assistive Technology • Controllable anatomical movements like eye blinks, head or neck movements, or mouth movements may be used to operate equipment that provides access to the computer • input devices that can be controlled by anatomical movements including switches, alternative keyboards, mouse, trackball, touch window, speech recognition, and head pointers

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Prescribers’ list: medication, who prescribed it, indication  Detailed history from client or family member Depression Contributors to elderly depression  Decrease in the production of important NT  Gender  Medical conditions  Situational life events: Lifestyle changes; financial stress; legal problems Depression Treatment  Psychotherapy: individual talk therapy; family therapy; group therapy or combination; reminiscence therapy and life review  Goals: behavior modification; adapting new coping skills; dealing with grief and losses  Medication: TCA; SSRI; MOAI  ECT  Suicide Risk factors  Family history  History of suicide attempts  Inpatient to an outpatient hospital facility status  Unemployment and living alone  Suicide Ideation: feelings of hopelessness, helplessness and unworthiness  Passive ideation  Active ideation Interventions  Passive: stay with the client; affirm self worth; acknowledge the client’s feelings; ask specifically if client is thinking of hurting or killing himself or herself  Active: client needs to know that statement is taken seriously; never leave a client alone Suicide Lethality  High: high completion of suicide  Moderate: allow for some rescue time between attempt and completion  Low: methods for getting attention Suicide Lethality Interventions  Ask: how are you going to kill yourself; do you have the means; when are you planning to kill yourself  Never left alone a person with specific suicide plan and means of completing suicide  Outpatient: take to an inpatient psychiatric facility  Inpatient: assess the plan, means and intent; constant watch; drug restraints; keep potentially harmful items away from client Organic Mental Disorders Factor Onset Delirium Rapid (hours or days) Fluctuates Dementia Gradual (years) Normal

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Level of consciousnes s Orientation

Confused, disoriente d Fluctuates

Confused, disoriente d Labile

Affect Nursing Interventions for Specific Problems and Supportive Care for the Elderly  Mental Health Issues  Depression  Suicide  Organic Mental Disorders  Substance Abuse  Assessment and diagnosis Intervening factors in diagnosing mental illness  Use of several doctors  Several medical problems  Numerous medications and treatment  Social concerns: transportation, economic  Losses with aging: independence, finances  Assessment and diagnosis Steps in diagnosing mental disorder in the elderly  Rule out underlying medical condition  “Brown bag” examination 

Sleep

Disturbed

Unusually normal Impaired

Cognition

Impaired

Factor

Delirium

Dementia

Memory

Impaired

Impaired

Thought content Judgment

Incoherent, confused Poor

Disorganized, delusional Poor

Insight

Present when lucid Poor, improves as condition improves Reversible

None

Mental status exam

Poor, worsens with time

Outcome

Irriversible

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Common types of Dementia Alzheimer’s disease  Degenerative disease that affects brain and ability to think and reason Vascular / Multi-infarct dementia  Decrease in mental abilities associated with multiple strokes Parkinson’s disease  Lack of dopamine Common types of Dementia Interventions  Treatment for delirium: treatment of underlying condition  Treatment for dementia: no cure  Use of psychotropic drugs with close monitoring  Physical and emotional supportive care for the client and family members  Assess, document and report any changes in physical and mental status  Reality orientation and acceptance of what people are Substance abuse Differential diagnosis  Substance dependence  Behavioral, cognitive and physiological symptoms of requiring a substance despite having no medical need to continue  Substance abuse  Person’s lifestyle centered around obtaining and using the substance to the point of not only neglecting major roles but also cause major problems in one’s life Substance abuse Legal substances commonly abused by the elderly  Analgesics  Narcotics  Sleep medications  Alcohol Illegal substance commonly abused by veterans  Amphetamines  Opiates  Cocaine  Heroin  Other hallucinogenic substance Substance abuse Interventions  Ask direct questions  Detoxification procedures with emergency medical back up  Drug rehabilitation  Support groups: socialization skills