GERIATRIC STUDY GUIDE

Infancy

Trust versus Mistrust

Toddler

Autonomy versus Shame and Doubt

Preschool

Initiative versus Guilt

School Age

Industry versus Inferiority

Adolescent

Identity versus Role Confusion

Young Adult

Intimacy versus Isolation

Middle Adult

Generativity versus Stagnation

Older Adult

Self Actualization/Integrity versus Despair

Young old

65 to 74

Middle Old

75 to 84

Old-Old

85 and above

Centenarian

100 and older

Gerontology

A study of the growing process of aging of normal, healthy and functioning individuals.

Gerone

A term given to people who are old but can gracefully function as a useful citizen in the home and in the community.

Geriatrics

A term given to people who are old or who behave old and signify's care given to old sick people.

Aging

A slow process of growth towards maturity of mind, body, spirit and comprises a series of changes that occur in all living organism.

Gerontological Nursing (Gerontology)

A specialty in nursing pertaining to the care of older adults in their normal development process.

Where the word geriatrics came from and what it means

From greek word "geras" (old age) "iatrics" (medicine)

What is Aging?

Aging is a continuous process from birth to death, which covers physical, social, psychological, and spiritual changes.

Theory

1. A cluster of conclusions in search of a premise

2. An explanation that makes sense to us of some phenomenon

Biological/Physical Theory

1. Stochastic Theory

2. Non-stochastic theory (pre-determine theory)

Stochastic Theory

Propose that chance error and the accumulation of damage over time cause aging

non-stochastic theory

View aging as certain predetermined, timed phenomena

Error theory

Aging as a result of an accumulation of errors in the synthesis of cellular DNA and RNA

Ex. Visible sign is the gray hair

Wear and Tear

Cell errors are the result of "wearing out" over time because of continued use and trauma; one of the earliest theory of aging

Ex. Shoulder pain of pitcher and knee of a run

Cross-link Theory

Explains aging in terms of the accumulation of errors by cross-linking or stiffening of protein in the cell

Proteins link with glucose and other sugars in the presence of oxygen and become stiff and thick

Psychological Theory

Explains aging in terms of mental processes, emotions, attitudes and motivations characterized by life stage transition

Human Needs

Five basic needs motivate behavior in a life long process:

Individualism, Stages of Personality, Life Course/Life span, Selective Optimization

Individualism

Personality consist of an ego, collective unconscious that views life from a personal and external perspective. Older adults search for meaning and adapt to functional and social issues

Stages of Personality

Personality develops in eight sequential stages with corresponding life developmental task.

The eight tasks, Integrity versus despair characterized by evaluating life's accomplishments, struggles includes letting go, accepting care, detachment and physical and mental decline

Life course/ Life Span

Life Stages are predictable and structured by roles, relationship, values, development and goals.

Persons adapt to changing roles and relationship.

Age group norms and characteristics are an important part of the life course

Selective optimization

Individuals cope with aging losses through activity/ role selection, optimization and compensation. Critical life points are morbidity, mortality, and quality of life.

Selective optimization with compensation facilitates successful aging

Theories of Aging according to Letty Kuan

Retirement and Role Discontinuities

Determinants of Fruitful Aging
Prepared retirement
Health Status
Income
Family Constellation
Self-Preparation

Retirement Role Discontinuities (Aging Process) leads to change of Life meets determinants resulting in Outcome of fruitful retirement and aging.

Sociological Theories

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

Activity

Remaining occupied and involved is necessary to a satisfying late life

Disengagement

Gradual withdrawal from society and relationships serves to maintain social equilibrium and promote internal reflection

Subculture

The elderly prefer to segregate from society in aging subculture sharing loss of status and societal negativity regarding the aged. Health and mobility are key determinants of social status.

Continuity

Personality influence roles and life' satisfaction and remains consistent throughout life. Past coping patterns recur as older adults adjust to physical , financial and social decline and contemplate death. Identifying with one's age group finding a residence compatible with ones limitations

Age stratification

Society is stratified by age group which is the basis for acquiring resources, roles, status and deference from others

Person Environment Fit

Function is affected by ego strength, mobility, health and cognition sensory perception and the environment. Competency changes once ability to adapt to new environment demands

Gerotranscendence

Elderly transform from a materialistic/ rational perspective toward oneness with the universe.

Programmed theory (non-stochastic theory )

1.) changes of aging to a process that is thought to be predetermined or ' programmed ' at the cellular level.

2.) this means that each cell has a natural life expectancy.

3.) as more cells stop or cease to replicate the signs of aging appear and ultimately the person "dies" at a predetermined age.

Free Radical theory

among the most understood and accepted theory

> it is believed that cellular errors are the result of random damage from molecules in the cells, called free radicals.

free radicals

are natural by product of cellular activity

> with aging the damage cause by free radicals occur faster than the cells repair as a result there will be cell death.

Based on the aging process is based on the hypothesis that with increasing age, mutations of the mitochondrial DNA will accumulate and will at least lead to a loss of function with subsequent acceleration of cell death. Even if this theory is widely accepted, the reactive-oxygen-species-induced mutations of mitochondrial DNA, the accumulation of mitochondrial DNA and the role of antioxidants are not fully understood

Neuroendocrine -Immunologic theory

changes in the integrated neuroendocrine and immune system.

> programmed deaths of the immune cells from damage caused by the increase of free radicals as aging progresses.

Nutrition theory

is the most logical theory to qualify long life

>one essential factor that promotes longevity is good nutrition.

> good nutrition is also the body's defense against disease.

> tissue cells, nerves, muscles and bones that are appropriately nourished with the proper nutrition all throughout the developmental stages maintain the structure and function of the body and its optimum activity.

Transition theory

shows the role of shifting or change of one situation to another on the aging process

> there are too many transition in one’s life and there is no adequate preparation that accompany that shifting of role or situation become a threat to the security of the individual and this will hasten aging

Evidenced based Practice

nursing follows a systematic approach that uses existing research for clinical decision making.

> best practice are evidenced based and are built on the expertise of the nurse.

Standard

reflect the level and expectations of care that are desired and serve as a model against which practice can be judged

> these serve to both guide and evaluate nursing plans.

Holistic gerontological care

incorporates knowledge and skills from a variety of disciplines to address the physical, mental, social, and spiritual health of an individuals.

Principles

are those given facts or widely accepted theories that guide nursing action.

As professional nurses are responsible for using these principles as the foundation of nursing practice.

Comprehensive Geriatric Assessment

A multidimensional, multidisciplinary diagnostic instrument designed to collect data on the medical, psychosocial and functional capabilities and limitations of elderly patients.

(As soon as we are able to assess and identify the limitations and capabilities, that’s the moment we can act upon or do the nursing assessment. How can I help my client?)

Importance of geriatric assessment

1. practitioners/ nurses use the information generated to develop treatment and long term follow up plans.

2. arrange primary care and rehabilitative services

3. organize and facilitate process of case management

4. determine long term care

5. make the best use of health care resources

Prevalent problems faced by the elder patient " FIVE I's of Geriatrics"

1. intellectual impairment

2. immobility

3. instability

4. incontinence

5. iatrogenic disorders

Assessment tools

1. physical health

2. motor capacity

3. manual ability

4. self care ability

5. instrumental abilities

6. cognitive functioning

7. social function

Three approaches used for collecting assessment data

Self report format, Report by proxy, Observation

Self report format

questions are either ask directly or the person is expected to respond to written questions about his or her health status

Report by proxy

obtained indirectly, that is the nurse asks another person, such as a staff nurse, aide, spouse, or child to report their observation

observation

the nurse collects and records the data, she or he has measured and observed the persons health status using objective parameter

Activities of Daily Living (ADL)

Patient's capacity for daily living.

D - Dressing
E - Eating
A - Ambulating (Walking)
T - Toileting
H - Hygiene

Instrumental Activities of Daily Living

S - Shopping
H - Housekeeping
A - Accounting
F - Food Preparation
T - Transportation

FANCAPES

A model for a comprehensive yet prioritized assessment that is especially useful for the frail elders:

F = Fluids
A = Aeration
N = Nutrition
C = Communication
A = Activity
P = Pain
E = Elimination
S = Socialization and social skills

Frailty

A stage of age related physiologic vulnerability from impaired homeostatic reserved and reduced capacity of the organism to withstand stress

= both physical and mental decline leads to an increased risk for morbidity and mortality

Chronic Illness

Conditions that last a year or more and require ongoing medical attention or limit activities of daily living.

Chronic Illness Nursing Perspective

Irreversible presence, accumulation or latency or disease state or impairments that involve the total human environment for

a. Supportive care
b. Self-care
c. Maintenance of function
d. Prevention of further disability

Categories of Chronic Illness (Nonfatal)

Conditions such as osteoarthritis, vision problem, these contribute to disability and increased health cost but most individual can live with them for many years.

Serious eventually fatal chronic illness

Lead to death ex cancer, organ failure, heart failure, stroke

Frailty

A condition in which the body has little reserve left and any disturbance can cause multiple health conditions and cost

Therapeutic

Nurse-Client Interaction/Nurse-client Relationship

Therapeutic Communication Techniques

Responsible, Assertive, and Caring Interactions in Practice.

THERAPEUTIC RELATIONSHIPS

Primary mode of implementing interventions in psychiatric nursing

Phases
Orientation
Working
Termination

EFFECTIVE NURSE BEHAVIOR

Active listening
Focus on client
Self-awareness
Professional caring
Genuine
Interest
Acceptance

INEFFECTIVE NURSE BEHAVIOR

Excessive self-disclosure
Anxiety
Distracting nonverbal mannerisms of behavior
Excessive talking
Asking multiple questions
Rushing the interaction process

Generalist

provide care according to
various models
> nursing experiences with elders across the
continuum of care
> nursing care in acute care setting or nursing
care in
a. retirement home
b. nutrition center
c. home care agency
d. adult day health program
e. senior housing
f. rehabilitation center

specialist

expertise in planning and
evaluating care
> advanced preparation of masters level

advanced clinical expertise

Acute care
Comprises 60 percent of medical – surgical patients
Chronic illness and injury

Community and home base care
Adult day health program
b. primary health clinic
c. retirement communities
d. independent senior housing

Long term care

comprises variety of health, social and personal care that is provided in caring for chronic illness, functional and
cognitive deficits

BOUNDARIES

General principles of boundaries in professional relationships

Special issues in mental health
Client’s perception of nurse’s actions
Setting for the interaction
Use of touch

ISSUES

Confidentiality
Privacy and dignity
Student concerns
What if no one will talk to me?
What if I say the wrong thing?
What if I can’t think of anything to say?
How can I ask personal questions without prying?

Therapeutic Communications

1. Purposes and Goals
2. Expressing feelings
3. Clarifying problems
4. Addressing client concerns
5. Resolving problems
6. Role playing alternatives

Verbal Skills & Behavior

1. Specific clear messages
2. Therapeutic communication techniques
3. Finding and responding to cues
4. Open-ended vs. close- ended questions
5. Directive vs. nondirective interaction

Nonverbal Skills and Behavior

Distance
Posture
Eye contact
Facial expression
Tone and volume of voice
Use of touch
Involvement in activity

Medication History

1. Nurses should take particular care in identifying all drugs the patient is currently taking

2. The record should obtain a list of all currently prescribed medications
- Including indication, dosage, schedule, and duration, all over the counter
- preparations, previously prescribed medications with the duration of use, date of discontinuation and reasons of withdrawal

3. Specific notes regarding drug allergies and reactions

Medical History

1. immunization history (tetanus, influenza, pneumococcal vaccine )
2. listing of previous illnesses and diagnosis
3. any previous operations or hospitalization
4. any blood transfusion
5. complete obstetric and gynecologic history for female patients

Personal and Social History

1. detailed description of alcohol use, tobacco, use and caffeine intake.
2. patients sleep pattern and use of medication
3. questions about frequency and ease of falling asleep , quality of sleep, snoring, napping and degree of daytime somnolence should be ask.

Dietary Assessment

The US National Screening Initiative develop a public awareness checklist that allows patients and caregivers to rate their nutritional health.

Recommendations for interventions are based on the score.

Nutrition

1. What is the type and amount of food consumed?
2. Does the person have the ability to bite, chew, and swallow?

Aeration

1. is the person's oxygen exchange adequate for full respiratory functioning?
2. Is supplemental oxygen required, is it possible for the person to obtain it?
3. What is the respiratory rate and depth at rest and during activity, talking, walking and exercise and while performing activities of daily living.

Mini-cog

it is used as a tool that could establish cognitive status more quickly without equipment needed

Components

3 item recall, give 3 items, ask to repeat, divert and recall

Clock drawing test

which has been used since 1992, is a screening tool that helps identify those with cognitive impairment and that is used as a measure of severity.

Instruction: On a piece of blank paper ask the elders to draw circle
Ask the elders to place the numbers 1-12 inside the circle as for a clock
Ask the elders to place the hands at 3:45

Mini- mental state examination

the tool that is most used, a 30 item instrument that is used to screen for cognitive deficiencies and is one of the factors in the determination of a diagnosis of dementia or delirium

instrumental activities of daily living

1. telephone
2. traveling
3. shopping
4. preparing meals
5. housework
6. medication
7. money

Mental Status Assessment

As persons enter their 80’s and 90’s their risk for impaired cognitive abilities increases, increase rate of illnesses such as Alzheimer’s .

The gerontological nurse must be aware of the basic tools that are used in the assessment of mental status especially cognitive abilities and mood.

Environmental History

1. Understanding of the living arrangement
2. Safety measure
3. Home evaluation which includes lighting, flooring, furniture locations and air conditioning
4. Kitchen, bathroom and stairway should be evaluated for safety, common sites for falls and injuries

Assessment for Depression

Patients should be asked about signs and symptoms related to their emotional condition

Scoring scale, one point for each of these answers. Cut –off score (0-5) normal above 5 suggest depression

Sexual History

Sexuality may be an important aspect of many geriatric patient including the oldest old.

Sexual history helps health practitioners evaluate medical, psychological and educational needs of the elder patient

Physical Examination

A. Vital sign- carefully and completely
Body temperature- oral and axillary
Pulse- pulse rhythms, pulse pressure
Blood pressure
Respiratory rate
Pain
B. General Appearance
Height
Weight
Skin inspection
C. HEENT Examination
Eyes- test visual acuity
Ears- use of an otoscope to detect cerumen
Hearing- simple test of hearing acuity such as rubbing two fingers or placing a ticking watch near the ear can be useful.

mini-mental state examination

the tool that is most used, a 30 item instrument that is used to screen for cognitive deficiencies and is one of the factors in the determination of a diagnosis of dementia or delirium.

>it tests orientation, short term memory, attention, calculation ability, language and construction.

>written test, administered to persons who are able to see and write.

Cardiovascular System

a. hypertension

b. coronary artery disease