Fundamentals Exam 3 - Older Adults, Grief, Death & Dying

Exam 3

SPICES nursing assessment for older adults assesses for

Sleep disorders, Problems with eating, Incontinence, Confusion, Evidence of falls, Skin breakdown

The SPICES nursing assessment helps identify

the most common syndromes in older adults that require nursing intervention

Common changes to the cough reflex in older adults

decreased cough reflex and ciliary activity

Common musculoskeletal changes to the chest in older adults

increased anterior-posterior chest diameter, increased chest wall rigidity

Common lung changes in older adults

fewer alveoli, increased airway resistance

Common blood vessel changes in older adults

thickening of blood vessel walls, narrowing of vessel lumen, loss of vessel elasticity

Common heart changes in older adults

lower cardiac output, decreased number of heart muscle fibers, decreased elasticity and calcification of heart valves

Common blood pressure changes in older adults

decreased baroreceptor sensitivity, decreased efficiency of venous valves, increased pulmonary vascular tension, increased systolic blood pressure, decreased peripheral circulation

Common digestion changes in older adults

periodontal disease, decreased saliva, decreased gastric secretions and pancreatic enzymes

Common stomach changes in older adults

gastric atrophy, decreased production of intrinsic factor, increased stomach pH, loss of stomach smooth muscle

Common GI changes in older adults

smooth-muscle changes with decreased peristalsis and small intestinal motility

Common rectal changes in older adults

hemorrhoids, rectal prolapse, impaired rectal sensation

Common musculoskeletal changes in older adults

decreased muscle mass and strength, de-calcification of bones, degenerative joint changes, dehydration of intervertebral disks, fat tissue increases

Common neurological changes in older adults

degeneration of nerve cells, decrease in neurotransmitters, decrease in rate of conduction of impulses

Common eye changes in older adults

decreased accommodation to near/far vision (presbyopia), difficulty adjusting to changes from light to dark, yellowing of the lens, altered color perception, increased sensitivity to glare, smaller pupils

Common ear changes in older adults

loss of acuity for high-frequency tones (presbycusis), thickening of the tympanic membrane, sclerosis of the inner ear, buildup of earwax (cerumen)

Common taste changes in older adults

often diminished, usually fewer taste buds

Common sense of smell changes in older adults

usually diminished

Common sense of touch changes in older adults

decreased skin touch receptors

Common proprioception changes in older adults

decreased awareness of body positioning in space

Common genitourinary changes in older adults

fewer nephrons, 50% decrease in renal blood flow by age 80, decreased bladder capacity; men - prostate enlargement, women - reduced sphincter tone

Common general endocrine changes in older adults

alterations in hormone production with decreased ability to respond to stress

Common thyroid changes in older adults

diminished secretions

Common cortisol and glucocorticoid changes in older adults

increased anti-inflammatory hormone

Common pancreas changes in older adults

increased fibrosis, decreased secretion of enzymes and hormones, decreased sensitivity to insulin

Common immune changes in older adults

thymus decreases in size and volume, T-cell function decreases, core temperature elevation is lowered

Delirium

an acute change in attention and awareness that develops over a relatively short time interval and is associated with additional cognitive deficits such as memory deficit, disorientation, or perceptual disturbances

Physiological causes of delirium

electrolyte imbalance, untreated pain, infection, cerebral anoxia, being on mechanical ventilation, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or hemorrhage

Hyperactive delirium

most common form of delirium, characterized by agitation, restlessness, emotional lability, and psychotic features such as hallucinations and illusions that often interfere with the delivery of care

New onset delirium assessments

s/s of infection - pneumonia, UTI

Environmental factors associated with delirium

sensory deprivation, overstimulation, unfamiliar surroundings, sleep deprivation

Psychosocial factors associated with delirium

emotional distress

Dementia-Delirium connection

dementia greatly increases the risk for delirium

Dementia

generalized impairment of intellectual functioning that interferes with social and occupational functioning

What diagnoses are included under dementia?

Alzheimer disease (most common), Lewy Body disease, frontal-temporal dementia, vascular dementia

Major difference between dementia and delirium

delirium is acute onset and usually reversible, dementia is gradual, progressive, and irreversible

Dementia care should focus on

enhancing quality of life and maximizing functional performance by improving cognition, mood, and behavior

Major safety concern associated with dementia

wandering

Depression

the most common, but undetected and untreated impairment in older adults. Often exists in and is exacerbated in patients with other health problems, such as stroke, diabetes, Parkinson disease, heart disease, cancer, and arthritis or other pain-provoking diseases

Primary factor in depression in older adults

loneliness - have experienced many losses, may have outlived everyone they know from their past

Sundowning

state of confusion that occurs in patients with delirium late in the afternoon and lasts into the night

Education strategies for older adults

Look for signs of pain or fatigue, create a comfortable environment, adapt teaching materials for culture, language, health literacy, focus on concrete information and relate to past experiences when appropriate, use printed materials with large black font on cream or white paper, use clear, concise language, avoid medical terminology, use visual aids when needed to augment spoken language, give time to process information and ask questions, use teach-back to assess effectiveness

Early indicators of acute illness in older adults

1. Changes in mental status

2. Falls

3. Dehydration

4. Decrease in appetite

5. Loss of functional ability

6. Dizziness and incontinence

What kinds of mistreatment could an older adult experience?

physical abuse, psychosocial or emotional abuse, financial abuse, sexual abuse, neglect

S/S of dehydration in older adults

confusion, dark-colored urine, not urinating frequently, few or no tears, dry mucus membranes, tenting/turgor, dry, sticky mouth, unexplained tiredness, high HR but low BP, dry cough, loss of appetite but may be craving sugar, flushed skin, swollen feet

Reality orientation

communication technique that makes an older adult more aware of person, place, and time. Includes frequent reminders of person, place, and time, the use of familiar environmental aids such as clocks, calendars, and personal belongings, and stability of environment, routine, and staff.

Validation therapy

an alternative approach to communication with an older adult who is confused. Accepts the description of time and place as stated by the older adult without challenging or arguing. Instead focuses on the emotional aspect of the conversation, which represents an inner need or feeling.

Reminiscence

method to recall past memories. Uses the recollection of the past to bring meaning and understanding to the present to resolve current conflicts.

Loss of possessions or objects implications

extent of grieving depends on value of object, sentiment attached to it, or its usefulness

Loss of known environment implications

occurs through maturational or situational events, or by injury or illness. Loneliness or uncertainty in an unfamiliar setting threatens self-esteem, hopefulness, or belonging

Loss of a significant other implications

close friends, family members, and pets fulfill psychological, safety, love, belonging, and self-esteem needs

Loss of an aspect of self implications

illness, injury, or developmental changes result in loss of a valued aspect of self, altering personal identity and self-concept

Loss of life implications

those left behind after a death grieve for the loss of life of a loved one. Dying people also feel sadness or fear pain, loss of control, and dependency on others

Grief

an individualized response to a loss that is perceived, real, or anticipated by the person experiencing the loss

Mourning

all of the ways in which an individual outwardly expresses grief and the behaviors taken to manage grief. Most mourning rituals are culturally influenced, learned behaviors

Bereavement

the time of sadness after a person experiences a significant loss through death

Normal (uncomplicated) grief

a common and universal reaction characterized by complex emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death

Anticipatory grief

experienced before the actual loss occurs, especially in situations of prolonged or predicted loss

Disenfranchised grief

experienced when a person’s relationship to the deceased person is not socially sanctioned, can’t be shared openly, or seems of lesser significance

Ambiguous loss

a type of disenfranchised grief that can occur when the person who is lost is physically present but not psychologically available, e.g., severe dementia or brain injury. Characterized by a lack of finality and unknown outcomes.

Complicated grief

a prolonged or significantly difficult time moving forward after a loss. A chronic and disruptive yearning for the disease, trouble accepting the death and trusting others, and may feel excessively bitter, emotionally numb, or anxious about the future. Involves prolonged symptoms of painful emotions and sorrow for more than 1 year.

Chronic grief

a normal grief response, except that it extends for a longer period of time. Can include years to decades of intense grieving.

Exaggerated grief

a person may exhibit self-destructive or maladaptive behavior, obsessions, or psychiatric disorders. High risk of suicide

Delayed grief

A person’s grief response is unusually delayed or postponed because the loss is so overwhelming that they must avoid the full realization of the loss.

Masked grief

the survivor is not aware that their behaviors that interfere with normal functioning are a result of a loss. Physical symptoms could be headache, heartburn, rashes, or tachycardia

Kubler-Ross Stages of Dying - Denial

The person can’t accept the fact of the loss. Psychological protection from a loss the person can’t yet bear

Kubler-Ross Stages of Dying - Anger

The person expresses resistance or intense anger at god, other people, or the situation

Kubler-Ross Stages of Dying - Bargaining

The person cushions and postpones awareness of the loss by trying to prevent it from happening

Kubler-Ross Stages of Dying - Depression

The person realizes the full impact of the loss

Kubler-Ross Stages of Dying - Acceptance

The person incorporates the loss into life

Kubler-Ross Stages of Dying

1. Denial

2. Anger

3. Bargaining

4. Depression

5. Acceptance

Bowlby Attachment Theory

1. Numbing

2. Yearning and searching

3. Disorganization and despair

   1. Reorganization

Bowlby Attachment Theory - Numbing

protects the person from the full impact of the loss

Bowlby Attachment Theory - Yearning and Searching

Emotional outbursts of tearful sobbing and acute distress. Common physical symptoms: tightness in chest and throat, shortness of breath, feeling of lethargy, insomnia, and loss of appetite

Bowlby Attachment Theory - Disorganization and Despair

Endless examination of how and why the loss occurred or expressions of anger at anyone who seems responsible for the loss

Bowlby Attachment Theory - Reorganization

Acceptance of the change, assumption of unfamiliar roles, acquiring new skills, building new relationships, beginning to separate from the lost relationship without feeling that its importance is lessened

Worden - Grief Tasks Model

1. Accepts the reality of the loss

2. Experiences the pain of grief

3. Adjusts to a world in which the deceased is missing

   1. Emotionally relocates the deceased and moves on with life

Rando’s “R” Process Model

1. Recognize the loss

2. React to the pain of separation

3. Recollect and reexperience the relationship with the deceased

4. Relinquish old attachments

5. Readjust to life after loss

   1. Reinvest by putting emotional energy into new people

Dual Process Model - Stroebe & Schut - Loss-oriented activities

Grief work, dwelling on the loss, breaking connections with the deceased person, and resisting activities to move past the grief

Dual Process Model - Stroebe & Schut - Restoration-oriented Activities

Attending to life changes, finding new roles or relationships, coping with finances, and participating in distractions, which provide balance to the loss-oriented state

Palliative care

focuses on the prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness. The goal is to help patients and families achieve the best possible quality of life. Valuable for patients with complex illnesses.

Hospice care

a philosophy and model of care that focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life. Gives priority to pain and symptom management, comfort, and quality of life. Pts usually have less than 6 months to live, but may be longer.