Physiologic Integrity and Gerontological Nursing Foundations
Professional Nursing Practice and Definitions
Florence Nightingale’s Definition: Nursing is putting the patient in the best condition for nature to act.
Virginia Henderson’s Definition: The nurse’s unique function is to aid patients, sick or well, in performing those activities contributing to health or its recovery (or to peaceful death) that they would perform unaided if they had the necessary strength, will, or knowledge. The goal is to help patients gain independence as rapidly as possible.
American Nursing Association (ANA) Definition: Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations.
Nursing’s View of Humanity (Wellness Wheel): Professional nursing practice views humanity through a multi-dimensional lens including: * Physiologic * Psychologic * Social * Spiritual * Intellectual * Career * Environmental
Scope of Nursing Practice: * Entry level * Certification * Advanced practice * Master's degree * Doctorate
Standards of Professional Nursing Practice: * Standards of Practice * Standards of Professional Performance
Clinical Judgment and Evidence-Based Practice
Clinical Judgment Definition: The application of nursing knowledge to assess a situation, make decisions, solve problems, and develop skills through experience.
Hierarchy of Evidence (from highest to lowest relevance): 1. Systematic reviews and meta-analysis of Randomized Controlled Trials (RCTs). 2. One well-designed RCT. 3. Well-designed controlled trials without randomization. 4. Well-designed case-control studies. 5. Systematic reviews of descriptive and qualitative studies. 6. Internal organization-quality/risk management data. 7. Opinion of authorities or expert committees.
Nursing Practice Frameworks Comparison: * National Council of State Boards of Nursing’s Clinical Judgment Model (CJM): Recognize Cues $\rightarrow$ Analyze Cues $\rightarrow$ Prioritize Hypotheses $\rightarrow$ Generate Solutions $\rightarrow$ Take Action $\rightarrow$ Evaluate Outcomes. * Nursing Process (ADPIE/AAPIE): Assessment $\rightarrow$ Diagnosis or Analysis $\rightarrow$ Planning $\rightarrow$ Implementation $\rightarrow$ Evaluation. * Tanner Model: Noticing $\rightarrow$ Interpreting $\rightarrow$ Responding $\rightarrow$ Reflecting.
Concept Mapping: A visual diagram of the nursing process showing the relationship between patient problems, interventions, and clinical data (labs, medications, causative stimuli, priority problems).
Clinical Judgment Map: Step-by-Step Application
Recognize Cues (Assessment): Identify abnormal or unexpected findings in the patient assessment.
Analyze Cues: Determine the priority problem. Develop an explanation for objective and subjective cues. Include history (), medications (), vital signs (), and signs/symptoms ().
Prioritize Hypothesis (Nursing Diagnosis): Must use the care plan book. Structure: Nursing diagnosis related to () priority problem as evidenced by () assessment cues.
Generate Solutions (Planning): Set goals (Specific, Measurable, Attainable, Realistic, Timely). Prioritize based on (Airway, Breathing, Circulation). * Short-term (ST) Goals: Targeted for attainment during the shift. * Long-term (LT) Goals: Targeted for attainment by discharge ().
Take Action (Implementation): Perform nursing interventions with rationales and appropriate citations. Require at least interventions per goal.
Evaluate Outcome (Evaluation): Determine if the plan/goals were met and if the patient improved.
Healthcare Delivery and Delegation
Care Delivery Models: * Team care * Total patient care * Case management * Telehealth
Delegation and Assignment: * Registered Nurse (RN) to RN: Assignment within the scope of practice. * Five Rights of Delegation: 1. The right task. 2. Under the right circumstances. 3. To the right person. 4. With the right directions and communication. 5. Under the right supervision and evaluation.
Matching Roles and Responsibilities: * Unlicensed Assistive Personnel (UAP): Measure and document vital signs on a stable adult patient; assist a patient with toileting and ambulation; collect a routine urine specimen. * Licensed Practical Nurse (LPN): Administer oral medications; reinforce teaching on the use of an incentive spirometer. * Registered Nurse (RN): Perform a comprehensive head-to-toe assessment; insert a peripheral IV; report abnormal findings to the healthcare provider.
Communication Frameworks: SBAR and CUS
SBAR Framework: * S (Situation): What is going on with the patient? (e.g., "Dr. Lu, this is Alex from your office. I'm calling about Mr. Webb. He has substantial discomfort and low urine output.") * B (Background): Clinical context. (e.g., "Mr. Webb is years old with a catheter following bladder cancer treatment.") * A (Assessment): What the nurse thinks the problem is. (e.g., "Temp of , urine is cloudy/red. I'm concerned about infection or a clogged catheter.") * R (Recommendation/Request): What to do to correct it. (e.g., "I would like him to come to the office. Should we get labs/blood cultures when he arrives?")
CUS Framework: * C: Concerned. * U: Uncomfortable. * S: Safety.
Care Continuum and Disease Prevention
Care Continuum Stages: Primary (Preventive) Care $\rightarrow$ Outpatient Clinic $\rightarrow$ Acute Care (Urgent Care, Emergency Dept, Hospitalization) $\rightarrow$ Long-term Care $\rightarrow$ Home Care.
Health Promotion (WHO 2021): The process of enabling people to increase control over and improve health. The intention is to "strengthen the host."
Three Levels of Prevention: 1. Primary Prevention: Prevention of the emergence of risk factors. Intervening in modifiable factors. * Examples: Immunizations, condoms, nutrition guidelines, vitamins, eliminating environmental contaminants. 2. Secondary Prevention: Actions to halt disease progression at its earliest stage through early diagnosis and treatment (screening). * Examples: Breast cancer screening, case-finding programs, health promotion in child health clinics. 3. Tertiary Prevention: Treatment to minimize the impact of disease and disability. Goal is to optimize management. * Examples: Diabetes management, rehabilitation to restore function and limit disability.
Illness Definitions: * Acute Illness: Rapid onset, short duration; patient returns to previous level of function (e.g., colds, flu, GI virus). * Chronic Illness: Prolonged illness with no cure; results in irreversible changes or disability; requires long-term management (e.g., Arthritis, COPD, Diabetes, Stroke, Heart Failure).
Seven Tasks of Chronic Illness: 1. Preventing and managing a crisis. 2. Carrying out prescribed treatment regimens. 3. Controlling symptoms. 4. Reordering time (schedule changes). 5. Adjusting to changes in the course of disease. 6. Preventing social isolation. 7. Attempting to normalize interactions with others.
Chronic Illness Trajectory (Corbin and Strauss): Onset $\rightarrow$ Stable $\rightarrow$ Acute $\rightarrow$ Comeback $\rightarrow$ Stable $\rightarrow$ Crisis $\rightarrow$ Stable $\rightarrow$ Comeback $\rightarrow$ Stable $\rightarrow$ Downward $\rightarrow$ Dying.
Gerontological Nursing and Demographics
U.S. Demographics: * In , nearly in residents were age . * By , life expectancy is predicted to be years for men and years for women. * The fastest-growing age group is (projected to reach by ).
Age Classifications: * Young-old adults: to years (usually healthy and independent). * Old-old adults: and older (often single females, dependent on family). * Frail old: Conditions interfere with independent living.
Ageism: A negative attitude that leads to discrimination and disparities in care.
Special Populations: * Chronically ill: Incidence triples after age . Most over have at least one condition (HTN, Arthritis, Heart Disease, Diabetes, Cancer, Stroke, COPD). * Cognitively Impaired: * Improves with age: Vocabulary, verbal reasoning, crystallized intelligence. * Declines in middle age: Mental speed, fluid intelligence. * Declines in old age: Short-term recall memory. * Constant: Long-term recall memory. * Rural Older Adults: Barriers include transportation, limited access to workers, lack of quality care, social isolation, and financial limits. * Frail Older Adults: Manifestations include unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, and low physical activity.
SCALES Assessment Tool (Nutritional Assessment): * S: Sadness or mood change. * C: Cholesterol, high. * A: Albumin, low. * L: Loss or gain of weight. * E: Eating problems (swallowing, poor dentition). * S: Shopping or food preparation problems.
Social, Legal, and Ethical Considerations for Older Adults
Ethnogeriatrics: Culturally competent care for older adults, respecting cultural practices, language, and food preferences.
Social Support Systems: * Primary: Family caregivers (preferred). * Semiformal: Senior centers, adult day care, religious organizations. * Formal: Health facilities, social welfare, government support.
Elder Mistreatment (EM): Intentional acts of omission or commission causing harm or risk to a vulnerable adult. * Statistics: of domestic EM is committed by family members. * Types: Physical, psychologic, sexual, financial abuse; neglect; abandonment; violation of personal rights. * Institutional EM: Includes failure to follow the care plan, misuse of restraints, over/under medicating, and isolation punishment. * Self-Neglect: Unable to meet basic needs, refusing help, living in squalor, higher mortality rates.
Social Services: * Medicare: Federally funded for age or those with disabilities/end-stage renal disease. Coverage is limited. * Medicaid: State-administered, needs-based program for low-income individuals; covers most long-term care.
Age-Friendly Health System’s Model of Care: Evidence-based practices focused on "What Matters" to the older adult and family to ensure no harm.
Effects of Aging on Drug Metabolism
Absorption: Gastric emptying rate and GI motility slow; active transport mechanisms decline.
Distribution: Lean body mass falls while adipose stores increase. Total body water declines (raising concentration of water-soluble drugs like digoxin). Plasma protein levels decrease (raising blood levels of free drugs).
Metabolism: Liver mass shrinks; hepatic blood flow and enzyme activity decline. Metabolism drops to to of the rate of young adults, prolonging drug half-life.
Excretion: Decline in renal blood flow, GFR, tubular secretion/reabsorption, and number of functional nephrons. Half-life for renally excreted drugs (like oral antidiabetics) increases.
Drug-Receptor Interaction: Brain receptors become more sensitive, making psychoactive drugs very potent.
Circulation: Vascular nerve control is less stable. Antihypertensives may drop BP too low; Digoxin may slow heart rate excessively.
Assessment Framework: SPICES (Sleep disorders, Problems with eating/feeding, Incontinence, Confusion, Evidence of falls, Skin breakdown).
Questions & Discussion
Case 1: Health Care Disparities and Women * Question: The nurse teaches a student nurse about health care disparities and older adult women. Which statement indicates understanding? * Correct Answer: "Women have fewer financial resources than men."
Case 2: Identifying Elder Abuse * Question: An older male has large bruises on both upper arms and says, "I must have bumped myself." What is the most appropriate initial action? * Correct Answer: Question the patient about his living situation and activities.