intro gerontological nursing_spring 2014 abridged
TRANSCRIPT
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Introduction to Gerontological Nursing
NURS 4100 Care of the Older Adult Spring 2014Joy Shepard, PhD(c), MSN, RN, CNE, BC
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Objectives
Explain different ways older adults are viewed in contemporary society
Describe major characteristics of today’s older population
Discuss projected demographic changes in future generations of older people and the implications for health care
Describe the nursing process in care of older adults Discuss standards, major roles, principles, and future
challenges for gerontological nurses
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"Old age is like everything else. To make a success of it you've got to start young."
Theodore Roosevelt
"Anyone who stops learning is old,
whether at twenty or eighty." Henry Ford
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Aging: A Natural Process… NOT a disease!
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Defining Old AgeChronological age – Exact age
from birthBiological age - Age determined by
physiology rather than chronologyFunctional age – Age in terms of
functional performance
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Activities of Daily Living (ADLs) Basic: Bathing (hygiene,
grooming) Dressing Eating Toileting Transferring
(mobility)
Instrumental: Light housework Preparing meals Taking medications Shopping for
groceries or clothes Using the telephone Managing money
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Characteristics of Aging Population “Typical” older person? Age 65 start of “old
age?” Energetic, vibrant,
influential, diverse Gerontology - identifies
common characteristics, problems, disease processes, & concerns
Nurse must consider individual differences & characteristics when planning & implementing care
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Gerontological Nursing
“The purpose of gerontological nursing is not to save lives, but to prevent untimely death and needless suffering. Both these goals include respect for human dignity – the preservation of personhood as long as life continues.”
-Doris Schwartz, 1989
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Definition of Terms Ageism - Prejudice, negative stereotyping based
solely on age Geriatrics - Branch of medicine that deals with
problems & diseases of old age, aging people Gerontology – Comprehensive, multidisciplinary study
of aging process & problems of older people with holistic focus, including biologic, sociologic, psychological, spiritual, & economic issues
Graying of America – Increased number older adults in US
Senescence - Process of aging within cells and organs accompanied by loss of organ function
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Definition of Terms Primary prevention – Activities directed
toward the protection from or avoidance of potential health risks
Secondary prevention – Activities designed for early diagnosis & treatment of disease or illness
Tertiary prevention – Activities designed to restore disabled individuals to their optimal level of functioning
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Gerontological Nursing: Specialty Area Nursing – caring for the vulnerable Gerontological nursing – newest &
youngest, most rapidly growing nursing specialty
‘Nursing’s forgotten… little understood specialty’
Challenging practice areas: complex In just 50 yrs…. foremost concern of health care
GerontologyGerontology: ComplexComplex FieldEncompassing ThreeThree Levels of Complexity
1. Normal aging changes
2. Chronic conditions associated with aging
3. Acute exacerbations of chronic conditions
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Development of Gerontological Nursing 1904: First article on care of the aged published in
the American Journal of Nursing 1914: Dr. I. L. Nascher—“Father of Geriatrics”—
first geriatric textbook 1935: Federal Old Age Insurance Law, or Social
Security 1950 – First geriatric nursing textbook 1962: First meeting of the ANA’s Conference
Group on Geriatric Nursing Practice
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Development of Gerontological Nursing 1965: formation of the Administration on Aging,
Older Americans Act, Medicare, & Medicaid 1966: Division of Geriatric Nursing—
gerontological nursing as a nursing specialty 1976 – Professional Standards for
Gerontological Nursing Practice (ANA) – Certification – geriatric nurses – 1st certification program by ANA
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Development of Gerontological Nursing Growth in the last few decades
– Increase in gerontological nursing texts– Increase in journal articles– Gerontological nursing education– Certification in gerontological nursing– Subspecialization– Hartford Institute for Geriatric Nursing
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Advanced Practice Nursing Roles Gerontological Clinical Nurse Specialist Gerontological Nurse Practitioner Preparation: unique principles, best practices
for older adult– Broad knowledge base– Capacity for independent practice – Leadership– Complex clinical problem-solving abilities
Programs Adult-Gerontology Nurse Practitioner
– ECU College of Nursing (Online) Adult-Gerontology Nurse Practitioner
– UNC-Chapel Hill School of Nursing Adult Gerontological Nurse Practitioner Concentration
– UNC-Greensboro School of Nursing Gerontological Nurse Practitioner
– Duke University School of Nursing Adult-Gerontology CNS & Adult-Gerontology Critical Care CNS
– Rush University (Online)
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In Great Demand… Challenges for the
future– Gerontological
nursing as a dynamic specialty
– Multitude of opportunities
– Development of new practice models
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Geriatric Patients… The Core Business of Health Care
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An Aging Population
Increased #’s older people, particularly “old-old” 41.4 million older adults in 2011 – 13.3% of the
population By 2030, adults 65 years, 20% of population 5.7 million 85+ population
– 2040: 14.1 million– 2050: 19 million
Source: A Profile of Older Americans http://www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf
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An Aging Population
As the aging population expands, it will affect all aspects of society (esp healthcare)
Currently 13.3% of U.S. population; consume disproportionate amount of healthcare resources
Aging-associated diseases – complications arising from senescense
2025: need an extra 260,000 full-time nurses to take care of aging population
Source: A Profile of Older Americans http://www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf
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Myths & Stereotypes of Aging
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Ageism Prejudice towards any
age group Defined as “the
prejudices and stereotypes that are applied to older people sheerly on the basis of their age….”
True or False???To be old is to be sick
?
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Myths & Stereotypes of Aging Many cultures: older people accorded respect American society is youth-driven
– Aging synonymous with death– Younger individuals – negative view of aging
process– Fear & lack of exposure to older individuals
contribute to ageism Older adults stereotyped: ill, bald, hard of
hearing, forgetful, rigid, grumpy, or boring
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Myths of Aging “You can’t teach an old dog new
tricks” “Dirty old man” Disease & disability are inevitable
part of aging Health promotion is wasted on
older people Elderly do not pull their own
weight Most people spend their last years
in nursing homes
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Myths of Aging Senility is a result of aging Incontinence is a result of
aging Older adults are no longer
interested in sexuality All elderly persons are
financially impoverished
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*Realities of Aging*
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Myths of Aging Lead to: Ageism Reduced healthcare services Segregation of elders from mainstream society Nurse recruitment difficulties Health professionals must be diligent in
avoiding age prejudice, as believing stereotypes can influence interactions between older adults & caregivers
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The Older Adult Population
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Subsets of the Older Adult Population Young-old: 65-74 yrs Middle-old: 75-84 yrs Old-old: 85-100 yrs Centenarians: 100+ yrs Diversity rather than
homogeneity
The Graying of the Population
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Number of Old and Old-Old
Distribution of the Projected Older Population by Age for the US: 2010 to 2050
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An Aging Population - Increased Life Expectancy Older adults currently 13% of U.S. population By 2030 – 20% of population Increasing life expectancy:
– 1900: 47.3 years– 1930: 59.7 years– 1965: 70.2 years– Present: 78.7 years (2010)– 2050: projected to be 82.6 yrshttp://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf
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First Wave of 76 Million Baby Boomers Started Turning 65 in 2011!
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Age Distribution of U.S. Population
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Factors Influencing Increased Life Expectancy Advancements in disease control & health
technology (esp. vaccines & antibiotics) Lower infant & child mortality rates Improved sanitation (clean water & sewage
disposal) Better living conditions
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Life Expectancy: Race and Gender Gap between women
& men (narrowing) Gap between Whites
& Blacks (narrowing)– Societal issues– Concern for nurses
Gender /Race
Whites Blacks Total
Females 81.3 78.0 81.1
Males 76.5 71.8 76.2
Total 79 75.1 78.7
http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf
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Marital Status & Living ArrangementsWomen more likely to be widowed,
living alone in old age More than half of women 65 are
widowedOlder men more likely to be married Potential for living alone increases with age
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Aging Women Women outlive men, outnumber
men 4 to 3– Feminization of later life
Women predominate at older ages, proportions increase with advancing age
– Health & socioeconomic problems of elderly = problems of elderly women
Study of gerontology – closely linked to study of women’s health
Potential problems:– Widowhood– Living alone– Poor
– Coping with loss of mate– Difficulty finding another
life companion– Lack of a caregiver– Financial problems
Gender Distribution of Elderly Americans, by Age Group, 2010
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Aging Men Shorter life expectancy,
die at younger age More likely to remarry if
widowed– Widows outnumber
widowers 5 to 1 Fewer financial problems
than women– More likely to have worked 30
years or longer, qualify for full Social Security benefits
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Marital Status of Older Adults
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Income of Older Adults 8.7% live below poverty level “Fixed” income “Asset rich and cash poor” – What does this
mean? Median net worth twice national average related
to home ownership Dependent on Social Security for more than half
of their income Women & minority groups poorer than white men
Geographic Distribution: Older Adults Greatest number
(percentage wise): Florida, Maine, West Virginia, Pennsylvania, Montana
Dramatic increases in past decade: Alaska, Nevada, Arizona, Idaho, Georgia
Lowest percentage: Alaska, Utah, Texas, Georgia, Colorado
North Carolina?50
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Illness in the Older Population
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Health Status of Older Adults:
Acute Conditions (p. 8)Relatively fewer acute illnesses (i.e.,
infections & parasites, colds, or influenza)Lower death rates from acute illnessesAfter an acute illness…
– Longer period of recovery – More complications
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Illness in the Older Population Chronic illness – major concern for older adult Chronic illnesses – cause disabilities, complicate
care, need skilled nursing care 80% – at least one chronic illness (i.e., heart
disease, diabetes, arthritis, or hypertension) Many elderly people with two or more chronic
illnesses (comorbid) Comorbidity: the presence of multiple chronic
conditions simultaneously Challenge: reach highest functional capacity
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Health Status of Older Adults:
Chronic ConditionsChronic Conditions Major problem: increases
with age Most have at least one
chronic disease; many have several (comorbidity)
Comorbidity: the presence of multiples chronic conditions simultaneously
Result: limitations in ADLs & IADLs
Leading cause: disability & death
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Leading Chronic Conditions (Box 1-3, p. 8)
1. Arthritis 2. Hypertension 3. Hearing impairments
4. Heart conditions 5. Visual impairments 6. Orthopedic
impairments
Question
The leading chronic condition associated with older adults is:
(A) Arthritis (B) Diabetes (C) Hearing impairments (D) Hypertension (E) Orthopedic impairments
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Question
Is the following statement true or false?
Chronic disorders most prevalent in the older adult population are ones that can have a significant impact on independence and the quality of life
CDC: Chronic Diseases are Leading Causes of Death & Disability in U.S.
*7 of 10 deaths each year are from chronic diseases
*1 of 2 adults (of all ages) at least 1 chronic illness
*Obesity: major health concern: 1 in 3 adults
*One-fourth of people with chronic conditions: At least one ADL limitation
*Arthritis: most common cause of disability: 19 million Americans report ADL limitationhttp://www.cdc.gov/chronicdisease/overview/index.htm#1
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Heart diseaseHeart disease Malignant neoplasms (cancer)Malignant neoplasms (cancer) Chronic lower respiratory dz (COPD)Chronic lower respiratory dz (COPD) Cerebrovascular dz (stroke)Cerebrovascular dz (stroke) Alzheimer’s diseaseAlzheimer’s disease Diabetes mellitusDiabetes mellitus Influenza/ pneumoniaInfluenza/ pneumonia Nephritis, nephrotic syndrome, nephrosis Accidents Septicemia
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Leading Causes of Death for Persons 65 Yrs of Age & Older (Table 1-3, p. 9)
http://www.cdc.gov/nchs/data/databriefs/db64.pdf
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Question
When planning a course about mortality rates for a group of elderly clients, emphasis should be given to which of these topics because it is the leading cause of death for ages over 65?– A. Heart disease– B. Cancer– C. Infectious diseases– D. Accidents
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Health Promotion & Disease Prevention
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Health Promotion Health promotion: “the science and art of helping people change
their lifestyle to move toward a state of optimal health" (American Journal of Health Promotion, 1986)
Multidimensional, enhances wellness, self-actualization & individual fulfillment (Pender, 2002)
Purpose:– Help older adults achieve a sense of well-being– Reduce premature mortality, enhance quality of life
The Health Continuum
Balance of physical, emotional, social, spiritual, and intellectual health
Healthy People 2020
Vision: A society in which all people live long, healthy livesA society in which all people live long, healthy lives Overarching Goals: Attain high quality, longer lives free of preventable disease,
disability, injury, and premature death Achieve health equity, eliminate disparities, and improve the
health of all groups Create social and physical environments that promote good
health for all Promote quality of life, healthy development and healthy
behaviors across all life stages
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Proposed Healthy People 2020 Goals for Older Adults Reduce the proportion of older adults who have moderate to
severe functional limitations. (Developmental) Reduce the proportion of unpaid caregivers of
older adults who report an unmet need for caregiver support services.
(Developmental) Increase the proportion of older adults with one or more chronic health conditions who report confidence in managing their conditions.
(Developmental) Reduce the proportion of noninstitutionalized older adults with disabilities who have an unmet need for long-term services and supports.
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Proposed Healthy People 2020 Goals for Older Adults Cont’d… Reduce the rate of pressure ulcer-related hospitalizations among
older adults. Increase the proportion of the health care workforce with geriatric
certification. Increase the number of States and Tribes that publicly report
elder maltreatment and neglect. Increase the proportion of older adults with reduced physical or
cognitive function who engage in light, moderate, or vigorous leisure-time physical activities.
Reduce the rate of emergency department visits due to falls among older adults.
Healthy People 2020: The Road Ahead
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70% Physical Decline due to Modifiable Risk FactorsInactivityPoor nutritionTobaccoAlcohol Lack of preventive care
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70% Physical Decline Modifiable Through
Physical activity Improved nutrition Smoking cessation Alcohol in moderation Prevention of injuries from
falls Improved use Medicare-
covered preventive services
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Question
Name modifiable risk factors for physical decline and illness in older adults…
Name non-modifiable risk factors for older adults…
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Health Promotion & Disease Prevention Chronic conditions develop
over time Older adults must be
alerted to means of preventing disease and reducing risks
Important components of health maintenance:– Knowledge of self-care– Participating in screening
tests
Nurses intervene using three levels of prevention– Primary– Secondary– Tertiary
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Health Promotion and Disease Prevention Nurses should be aggressive in health promotion efforts Older adults must be alerted to means of preventing
disease & reducing risks– Take advantage preventive health services– Make healthy lifestyle changes
Preventive care: most effective strategy to reduce risk of disability & chronic illness– HP 2020 goal: “Attain high quality, longer lives free of
preventable disease, disability, injury, and premature death”
Primary Prevention
In primary prevention, a disorder is actually prevented from developing…
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Primary Prevention – Health Promotion Behaviors Education: Patient, family, caregiver; health care provider
– Falls prevention– Pressure ulcer prevention
Immunizations– Influenza, pneumococcal, tetanus/diphtheria, hepatitis B
Maintain body weight ( 10% age-adjusted normal weight) Regular physical activity (as appropriate) Nutritional assessment & guidance
– Well-balanced diet Fiber, calcium, vitamin D
Avoidance of tobacco Alcohol in moderation
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Primary Prevention – Health Promotion Behaviors Eight hours of sleep a night Positive mental attitude
– Encourage family members to participate in positive life review with elderly client
At least one friend to trust & confide in Self-discipline to enjoy pleasant things in moderation Relaxing & pleasant activities to look forward to Limiting exposure or avoiding known carcinogens
Secondary Prevention
In secondary prevention, disease that has not yet become symptomatic is detected and treated early, thereby minimizing serious consequences…
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Secondary Prevention – Early Diagnosis, Prompt Treatment Important components of
health maintenance practices – Self-care, screening– Regular visits PCP– Reduce cholesterol– Monitor blood pressure
Appropriate diagnostic, screening tests:– Fecal occult blood test– Glaucoma screen (tonometry &
visual field testing)– Fasting glucose– Colonoscopy– Prostate exam: PSA & DRE– Mammogram– Pap test, pelvic– Bone mass screening
Tertiary Prevention
In tertiary prevention, an existing, usually chronic disease is managed to prevent complications or further damage. For example, tertiary prevention for people with diabetes focuses on tight control of blood sugar, excellent skin care, frequent examination of the feet, and frequent exercise to prevent heart and blood vessel disease…
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Tertiary Prevention – Restoration, Rehabilitation Manage clinical diseases (esp chronic diseases) to prevent
them from progressing– Aim: optimal functioning; avoid disability & complications
Rehabilitation (physical, occupational, speech, recreational therapy) – Short-term placement or– Aggressive in-home rehabilitation
Appropriate services/ aids to increase independence – Walkers, canes, homemaker/ home health aid, visiting nurse
Disaster relief – Safe housing, counseling, physical care
Question
Which of the following is an example of primary prevention?
A. Administering digoxin to treat heart failure B. Obtaining a smear for a screening test C. Using occupational therapy to help a patient
cope with arthritis D. Vaccinating an older adult during the flu
season
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Question
The gerontological nurse is teaching 86-year-old Patricia Smith and her family about exercise programs for the elderly. Which of the following statements about arthritis is an example of tertiary preventive care?– A. Exercise cures arthritis– B. Exercise can help control and manage the symptoms of
arthritis and prevent complications– C. Exercise is important for healthy joints and it also
strengthens the surrounding muscles– D. Exercise helps prevent arthritis from developing
Question
Which of the following describes secondary prevention?
A. aims to prevent disease from developing in the first place B. aims to detect and treat disease that has not yet become
symptomatic C. directed at those who already have symptomatic disease,
in an attempt to prevent further deterioration, recurrent symptoms and subsequent events
D. set of health activities that mitigate or avoid the consequences of unnecessary or excessive interventions in the health system
Question
As they get older, men are more likely to be screened for prostate cancer: 48% of men 50 to 59 years as compared to 56% of men 80 years and older. The nurse concludes that this is:
A. An example of ageism and negative stereotyping B. An illustration of the belief that primary prevention
strategies should be promoted in the older adult population C. A proper allocation of scarce health care resources D. A societal trend based on higher numbers of aging men
Question While Medicare pays for some medical screenings for older
Americans, nine of every ten adults over the age of 65 go without screenings, such as bone mass screenings, colorectal cancer screening, glaucoma screenings, mammograms, and pap tests and pelvic examinations. Findings show that primary care providers are less aggressive when recommending preventive measures to the elderly.
The nurse concludes that this is: A. An example of ageism B. An illustration of the belief that tertiary prevention strategies are
wasted on elders C. A proper allocation of scarce health care resources D. Correct, since there is no need for aggressive screening measures
within this age group
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Prolongation of Frailty vs Compression of Morbidity?
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Functional Assessment of the Older Adult
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Nursing Process and the Older Adult Assessment
– Health History– Physical Examination
Goal: Individualize & tailor assessments and interventions to each patient
Functional abilities should be a central focus of comprehensive assessment
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Assessment of Function
Three domainsThree domains: ADLs, IADLs, & mobility Systematic, focus on individual needs Two approaches: asking & observing Basis for care planning, goal setting, &
discharge planning Eligibility to obtain many services
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Assessment
Health History– Nurse draws facts and interpretations from
older client that will shed light on current health status and health concerns
– Eliciting data requires time & patience on the part of both the nurse and client
– Nurse may interview client & client’s support members
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AssessmentPhysical Examination
• Nurse must be knowledgeable about normal physical changes of aging in order to conduct physical examination
• Client may need assistance with disrobing or position changes
• Be alert to potential for injury
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Challenges in Health and Functioning Adjustment to a new body image Effect on body image and self-concept Self-concept and roles Acceptance of bodily changes Declining function resulting in illness and
disability Loss of independence
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Diagnoses Frequently Seen in the Older Adult Impaired Physical Mobility Activity Intolerance Risk for Injury, Falls Risk for Infection Self-Care Deficits Social Isolation Risk for Loneliness Acute, Chronic Confusion
Imbalanced Nutrition Impaired Home
Maintenance Ineffective Role
Performance Ineffective Health
Maintenance Ineffective Therapeutic
Regimen Management
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Important Qualities of the Gerontological Nurse
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“The care of old people requires just as much skill, tact, ingenuity, and patience as the care of children, and perhaps more, because one must keep in mind that old people cannot be treated like children and that feebleness of physical and mental powers is not accompanied by forgetfulness of early experiences. A genuine affection, gentleness, sympathy, and imagination sufficient to grasp the patient’s point of view are necessary.”
Jessie Breeze, private duty nurse, 1909
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Important Qualities of the Gerontological Nurse Ability to form a
therapeutic relationship with elderly adults
Appreciation of the uniqueness of elders
Clinical competence in basic nursing skills
Good communication skills
Knowledge of physical & psychosocial changes that occur with age
Ability to work with & supervise others
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Therapeutic Communication
Ongoing, continuous, dynamic process
Includes verbal and nonverbal signals
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Nonverbal Communication Nonverbal communication
composes up to 80% of information exchange– Body language– Position– Eye contact– Touch– Tone of voice– Facial expression
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Verbal Communication Guidelines Do not yell or speak too
loudly to patients – Yelling into a hearing aid can
be disturbing and painful
Try to be at eye level Minimize background
noise
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Verbal Communication Guidelines Touch if appropriate
and acceptable Supplement with
written instructions as needed
Avoid complicated explanations
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Verbal Communication Guidelines Ask how the patient
would like to be addressed
Avoid demeaning terms such as sweetie, honey, or dearie
Use caring responses and careful listening
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Verbal Communication Guidelines Use open-ended statements
– “Tell me more…” or “How does this affect you?”
Avoid misunderstandings by clarifying– “I’m not sure what you mean…”
Encourage reminiscing