NCLEX-RN: Gerontological Nursing

Gerontological Nursing: General Concepts of Aging

Focus topic: Gerontological Nursing

Gerontological Nursing: General Concepts

Focus topic: Gerontological Nursing

A. Aging is an individual process.
B. Most older persons view their health as a positive state.
C. Coping with life has been successful because the person has “survived” to be old.
D. “Normal” aging may be confused with disease process in aging persons.

  • Illness is frequently misdiagnosed as “normal” aging.
  •  Because of “decline” due to “normal” aging, symptoms are neglected by family and medical personnel.
  •  Older persons underreport symptoms of illness because they interpret symptoms as “growing older.”

E. Most older persons have more than one chronic disease.
F. Chronological age is simply the number of years a person has lived.
G. Functional age refers to the person’s ability to function effectively within society.

Gerontological Nursing: Definitions Relating to Older Adults

Focus topic: Gerontological Nursing

A. Gerontology: scientific study of the process of aging; examining the changes that occur as a person ages; study of the needs of the older adult.
B. Aging: process of growing older; physiological changes in body systems as the person grows older; a biological/physiological process influenced by emotional state and social context.
C. Life span: maximum life potential for survival of a species.
D. Life expectancy: average number of years a person can expect to live
E. Frail old: person 75 years of age or older with some impairment in ability to provide functional self-care.
F. Gerontological nursing: use of the nursing process in caring for the physiological, psychological, and sociological needs of the aging person.

 Gerontological Nursing

Gerontological Nursing: Demographics

Focus topic: Gerontological Nursing

A. In 2030, the U.S. population will include > 35 million persons, 21% of the total over the age of 65 years.

  •  The post–World War II “baby boom” babies reached senior status around the year 2010.
  •  The number of persons over 65 years of age grew from 34 to 40 million between 1995 and 2010, an increase of nearly 20%.

B. Average life expectancy in the United States hit a new high of 78.7 years in 2012, up from 77.6 years in 2003. Life expectancy increased for both men and women and for whites and blacks.

  •  For men, life expectancy increased from 74.3 years in 2000 to 76.2 in years in 2010.
  •  For women, life expectancy increased from 79.7 years to 81.1 years in 2010.
  •  White females live approximately 4.9 years longer than white males.
  •  African American females live approximately 9 years longer than African American males.
  • White females live approximately 5.2 years longer than African American females.

C. Persons reaching age 65 have an average life expectancy of an additional 18.8 years (20.0 years for females and 17.3 years for males).
D. Increased life expectancy due to

  • Advanced health care.
  • Decreased infant/child mortality.
  • Improved nutrition and sanitation.
  •  Increased infectious disease control.

E. Five to 10% of older adults are alcohol abusers.

Gerontological Nursing: Healthcare Costs

Focus topic: Gerontological Nursing

A. Government spending for health care of older adults has increased nine-fold since 1970 and now tops $900 billion.

  • Healthcare services are used more by the aged person.
  •  The older the age of the person, the longer the stay in the hospital.
  • Older persons personally pay just over 50% of the cost of their health care. The remainder is paid by Medicare, Medicaid, and insurance.

B. The percentage of aged who live in nursing homes is 4–6%.

  •  Twenty-two percent over age 85 are in nursing homes.
  •  Before death, 20–27% of the aged use institutional care.

C. Nursing home residents have an average of 3.9 diseases.

  •  Over 40% have more than one illness.
  •  Diseases may be multiple and chronic.
  •  In 2009, nursing home population was 1.7 million. An upward trend is expected to continue for the next several decades.

D. Eighteen percent of older adults die at home.
E. Institutional placement most often results from a lack of social support as families become exhausted with care giving.

Gerontological Nursing: Morbidity and Mortality

Focus topic: Gerontological Nursing

A. Since 2009 there were decreases in several leading causes of death. Stroke was down by almost 5%, heart disease 4%, cancer 2%, and accidents 2%.
B. In 2010 the leading causes of death (in order of frequency) were: diseases of the heart, cancer, chronic lower respiratory diseases, cerebrovascular diseases (stroke), accidents (unintentional injuries), Alzheimer’s disease, diabetes mellitus, nephritis, nephrotic syndrome and nephrosis (kidney disease), influenza and pneumonia, and intentional self-harm (suicide).
C. Three out of four older adults die of heart disease, cancer, or stroke.

  •  Heart disease is leading cause of death in the United States, although it has declined since 1968.
  •  Death rates from cancer continue to rise, especially lung cancer.
  •  Death statistics for people in the 65 to 74 age group:
    a. Heart disease accounted for 38% of deaths.
    b. Cancer accounted for 30% of deaths.

D. Leading chronic conditions for older adults.

  •  Arthritis.
  •  Hypertensive disease.
  •  Heart conditions.
  •  Hearing impairments.
  •  Visual impairments.
  •  Dementia.

E. Objectives are to maintain vitality and independence of people age 65 and older.

Gerontological Nursing: Theories on Aging

Focus topic: Gerontological Nursing

A. Biological.The Aging Body

  •  Cellular. As cells are damaged, there is instability in the body.
    a. Free radicals—oxidation releases chemicals that affect the cell membrane and DNA replication.
    b. Cross-link—chemical bondage of elements that are generally separated.
    c. Doubling/biological clock—a cell has a genetically predetermined number of replications (Hay flick’s theory).
    d. Stress—homeostatic imbalance causes wear and tear on the organism.
    e. Error catastrophic transcription errors in the RNA and DNA, leading to cell mutation, which is perpetuated.
  •  Immunity. The thymus and bone marrow become less functional, so the body is less protected.

B. Psychological.

  •  Adaptation to stress—genetic makeup and personal learning to deal with life crises.
  • Life experience.
    a. Disengagement—the person and society let go of each other.
    b. Dependence—reliance on others for satisfaction of physical and emotional needs.

C. Sociological.

  •  Cultural and role expectation—relates to adaptation/dependence when defining level of activity/behavior/wellness.
  •  Environment—toxins and pollutants.

Gerontological Nursing: Nursing Process in Caring for the Aged Person

Focus topic: Gerontological Nursing

Gerontological Nursing: System Assessment

Focus topic: Gerontological Nursing

A. Priority—determine individual’s capacity for safe, functional self-care.
B. Utilize multidimensional approach to provide basis for individualized care plan.

  •  Physiological.
    a. Structural changes, normal and abnormal.
    b. Signs of chronic illness.
    c. Signs of medication effects.
  •  Psychological.
    a. Mentation.
    b. Motivation.
    c. Needs.
  •  Sociological.
    a. Usual and preferred living arrangements.
    b. Status of social network and caregiving.

C. Assess altered presentation of data.

  •  Complex interrelationship between aging and chronic and acute illness.
  •  Signs and symptoms of illness atypical or lacking.

Gerontological Nursing: System Implementation

Focus topic: Gerontological Nursing

A. Perform and/or supervise needed care.
B. Support level of self-functioning to maintain independence.

C. Maintain safety precautions.

  •  Side rails when in bed but have been found not to prevent injury.
    a. Watch for disorientation when client awakens.
    b. Prevent falls due to decreased muscle mass and decreased balance.
    c. Prevent orthostatic hypotension.
  •  Bed in low position when not giving direct client care.
  •  Handrails in bathrooms and halls.
  •  Uncluttered rooms and floors.
  • Adequate, non glare lighting.
  • Restraints when necessary.
    a. Older adults should only be restrained if they are in immediate physical danger or are hurting themselves or others, and then only for a short period of time.
    b. Restraint alternatives should be implemented to keep the client or resident safe from falls (wall-to-wall carpeting, pads placed on the floor, use of chair and bed alarms, or continual observation).

D. Provide psycho social care.

  •  Encourage psychological activity to aid sense of normality.
  •  Encourage verbalization about the past.
  •  Assist in selecting and attending activities.
  •  Foster touching, which is a very useful tool in establishing trust.
  •  Provide dignity and the feeling of worth.
  •  Foster the wellness approach to life.
  •  Care plans should be collaborative with client.

E. Teach family how to help/cope.

Gerontological Nursing: The Aging Body

Focus topic: Gerontological Nursing

Gerontological Nursing: Physiological Implications

Focus topic: Gerontological Nursing

A. Physical changes.

  •  Decrease in physical strength and endurance.
  •  Decrease in muscular coordination.
  •  Tendency to gain weight; redistribution of fat, decreased subcutaneous tissue.
  •  Loss of pigment in hair and skin.
  •  Increased brittleness of the bones.
  •  Greater sensitivity to temperature changes with low tolerance to cold.
  •  Degenerative changes in the cardiovascular system.
  •  Decreased sensory faculties.
  •  Decreased resistance to infection, disease, and accidents.

B. Intellectual impairment may be present.

  •  May develop in both cognitively intact and cognitively impaired older adults.
  •  The exact cause of delirium is not fully understood. Risk factors for delirium include: previous brain pathology, decreased ability to manage change, sensory impairment, presence of acute and chronic disease, changes in medication, translocation, cognitive impairment, sensory impairment or deprivation, comorbidity, depression, alcohol use, physical restraints, malnutrition, urinary catheterization, taking more than three medications, iatrogenic events.

Gerontological Nursing: Psychological Implications

Focus topic: Gerontological Nursing

A. Fears about losing job—focus for living.
B. Competition with younger generation.
C. Relationships change.

  •  Loss of nurturing functions within family.
  • Role change within and outside of family.

D. Loss of spouse, particularly females.
E. Realization that person is not going to accomplish some of the things that he or she wanted to do may lead to depression.
F. Physiological changes in body.
G. Changes in body image.
H. Illness.
I. Fears of approaching old age and death.

Gerontological Nursing: Developmental Tasks of Older Adults

Focus topic: Gerontological Nursing

A. Maintains ego integrity versus despair (Erikson).

  • Integrity results when an individual is satisfied with his or her own actions and lifestyle, feels life is meaningful, remains optimistic, and continues to grow.
  •  Despair results from the feeling that he or she has failed and that it is too late to change.

B. Continues a meaningful life after retirement.
C. Adjusts to income level.
D. Makes satisfactory living arrangements with spouse.

  •  Adjusts to loss of spouse.
  •  Maintains social contact and responsibilities.

E. Faces death realistically.
F. Provides knowledge and wisdom to assist those at other developmental levels to grow and learn.
G. Developmental process retrogresses.

  •  Increasing dependency.
  • Concerns focus increasingly on self.
  •  Interests may narrow.
  • Needs tangible evidence of affection.

Gerontological Nursing: Sociological Implications

Focus topic: Gerontological Nursing

A. Major fears of the aged.

  • Physical and economic dependency.
  •  Chronic illness—high percentage of older adults have chronic problems.
  •  Loneliness.
  • Boredom resulting from not being needed.

B. Major problems of the aged.

  • Economic deprivation.
    a. Increased cost of living while income remains fixed.
    b. Increased need for costly medical care.
    c. Increased poverty rate for persons age 65 and older.
    (1) Women, African Americans, Hispanics, and those who live alone are poorest.
    (2) Major source of income is Social Security (35%).
  • Chronic disease and disability.
  •  Loneliness and social isolation.
    a. Suffer losses of friends.
    b. Men die earlier, so many women are on their own.
    (1) Five times more women than men are widowed.
    (2) Half of older women are widows.
  •  Visual impairment.
  •  Organic brain changes.
    a. Most people have memory impairment.
    b. The change is gradual.

C. Death in the life cycle.

  •  In U.S. culture, death is not considered a positive process.
  •  Older adults may see death as an end to suffering and loneliness.
  •  Death is not feared if the person has lived a long and fulfilled life, having completed all developmental tasks.
  •  Religious beliefs and/or philosophy of life are important.

D. Older adults may provide knowledge and wisdom from their vast experiences, which can assist those at other developmental levels to grow and learn.

Gerontological Nursing: Elder Abuse and Neglect

Focus topic: Gerontological Nursing

Characteristics
A. Over 1 million older adults are estimated to be abused or neglected.
B. Seldom reported to authorities even though there is often a pattern of repetition.
C. Typical victim.

  • 1. Older women with limitation in one activity of daily living (ADL).
  •  Most are widowed.
  •  Caucasian.
  •  Low income.
  • Dependent on abuser for some aspect of care.

D. Abused is associated with

  •  Substance abuse.
  •  Caregiver strain.
  •  Depression.

E. Forms of elder abuse.

  • Physical: intentionally inflicting injury or pain.
  • Emotional: verbal harassment, intimidation,
  • denigration, or isolation.
  •  Sexual abuse: any non-consensual touching or sexual contact.
  •  Neglect: deteriorating health, dehydration, malnutrition, failure to provide food or services or care necessary to maintain health and safety; pressure ulcers, dirt, body odor, over or under medication.
  •  Financial: improper or unauthorized use of funds or property or power of attorney.

F. Suspect abuse if client has unexplained injuries or conflicting stories from client and caregiver.
G. All states have enacted elder abuse laws designed to protect older or vulnerable adults from abuse.
H. Majority of states require nurses and other healthcare providers to report cases of suspected elder abuse (to ombudsman).

  •  Standard for reporting is “reasonable” belief.
  •  Most states provide immunity from civil and criminal liability.
  •  Support suspicions with documentation and witnesses.

Assessment
A. Ask client and caregiver to explain injury.

  •  If client appears to be a victim, separate from caregiver and question.
  •  Follow up by documenting and report according to facility policy.

B. Assess physical injuries for abuse.

  •  Multiple injuries or fractures.
  •  Bruises or burns.
  •  Sprains or dislocations (frequent falls).

C. Assess for neglect (a form of abuse).

  • Deteriorating health, failure to thrive.
  •  Dehydration or malnutrition.
  •  Pressure ulcers or contractures.
  •  Over- or under medication.
  •  Excessive dirt or body odor.

D. Question client about emotional or financial abuse.

Implementation
A. Report all cases of suspected elder abuse (to ombudsman) even if there is no direct evidence just a “reasonable” belief that abuse is present.
B. Promote family problem-solving actions to resolve situation.

Gerontological Nursing: General Physiological Changes

Focus topic: Gerontological Nursing

A. Cells.

  •  Fewer in number.
  •  Larger in size.
  •  Decreased total body fluid due to decreased intra-cellular fluid.

B. Ear.

  •  Age-related changes can result in hearing loss.
  •  Presbycusis (sensorineural hearing loss).
    a. Progressive hearing loss in inner ear.
    b. High-frequency tones are lost first.
    c. Sounds are distorted; difficulty understanding words when other noises are in the background.
    d. Present in 30–40% of those over age 65.
    e. No clear-cut cause.
    f. May be due to insults from
    (1) Noise exposures.
    (2) Systemic or vascular disease.
    (3) Nutrition.
    (4) Ototoxic drugs.
    (5) Pollution exposure.
  •  Tympanic membrane atrophic, sclerotic.
  •  Cerumen accumulates; may become impacted due to increased amount of keratin.

C. Eye.

  •  Presbyopia—vision impairment caused by diminished power of accommodation from loss of elasticity of lens.
  • Pupil sphincter sclerosis with loss of light responsiveness.
  •  Cornea more spherical.
  • Lens more opaque.
  •  Increased light perception threshold.
    a. Adapt to darkness more slowly.
    b. Difficulty seeing in dim light.
  • Loss of accommodation.
  • Decreased visual field; less peripheral vision.
  • Decreased color discrimination on blue/green end of scale.
  •  Distorted depth perception.
  • Glare intolerance.
  •  Reduced lacrimation.

D. Vital signs.

  •  Blood pressure increases with age; there is a higher incidence of hypertension in men than women up to age 70.
  •  Heart rate remains unchanged.
  •  Respiratory rate unchanged.
  •  Core temperature unchanged.
  •  Prone to hypothermia.

E. Mood.

  •  Suffer multiple losses.
  •  Neurological changes.
  •  Loss of environment and interpersonal stimuli.
  •  Defense mechanisms are less effective.

Gerontological Nursing: Baseline Admission Assessment

Focus topic: Gerontological Nursing

A. Temperature.

  •  May be as low as 95°F or 35°C.
  •  A core temperature reading is the most accurate.
  •  Easily dehydrated with increased temperature.

B. Pulse.

  •  Rate, rhythm, volume.
  • Apical, radial, pedal, other sites as indicated by disorder.

C. Respirations.

  •  Rate, rhythm, depth.
  •  Irregularity common.

D. Arterial blood pressure.

  •  Lying, sitting, standing.
  •  Postural hypotension is common.
  •  Hypertension (160/95 mm Hg or greater).

E. Weight—gradual loss in late years.
F. Orientation level.
G. Memory.
H. Sleep pattern.
I. Psychosocial adjustment.

  •  Depression.
  •  Paranoia.
  •  Loneliness.
  •  Increasing dependency.
  •  Concerns focus increasingly on self.
  •  Displays narrower interests.

J. Immunization history.
K. General appearance.

  •  Gray and thinning hair.
  •  Wrinkled, pigmented, and thin skin.
  •  Eyes slightly sunken.
  •  Ears/nose appear slightly larger.
  •  Responds more slowly to questions and directions.
  •  Normal aging—intake of new information and abstract reasoning is prolonged.
  •  Trunk thicker; thinner arms and legs.
  •  Gait slower and less steady.
  •  Slower movements.
  •  Possible slight tremor.
  •  Decreased flexion of spine/limbs.

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