Care of Chronically Ill, Elderly Clients, and Hospice Care – Asst. Prof. Osel Sherwin Y.

Melad L Y S H O I // P A G E | 1
July 29, 2015  May be unable to work at self- 8. Managing chronic conditions is a collaborative
Chronic Conditions sufficiency tasks process
- Medical conditions or health problems with o School-age 9. Management of chronic conditions is expensive
associated symptoms or disabilities that require  May be unable to stay abreast of 10. Raise difficult ethical issues for the patient, heath
long-term (3 months) or longer management school work/participate in school care professionals, and society
- Ex. Mental retardation, blindness, paralysis, CVD, activities 11. Living with chronic illness means living with
DM, COPD, MS (may be due to congenital defects  Adolescents and young adults uncertainty
or accidents) o May have obstacles that prevent them from
- Usual S/Sx – pain and weakness/fatigue reaching their goals and becoming Phases of Chronic Illness
independent 1. Pre-trajectory phase
Chronic Illness  Young to middle-aged adults o Person is at risk due to genetics or
- The irreversible presence, accumulation, or latency o Chronic condition can complicate lifestyle which make them susceptible to
of disease states or impairments that involve total conception and completion of goals and disease
human environment for supportive care and self- dreams 2. Trajectory
care, maintenance of function, and prevention of  Older adults o Manifest S/Sx of disease
further disability (and prevent complications) o Life expectancy: year 2000 = 75 years old o Uncertainty is present
o As one ages, diagnoses of chronic 3. Stable phase
Disease vs. Illness disorders frequently multiplies o Disease condition under control
o Longer life expectancy 4. Unstable phase
Disease  Periods of disability, vulnerability o Recurrence 0f disease condition
- A condition that the practitioner views from a to other health problems, financial o Development of complications
pathophysiological model expense, increasing care concern o Exacerbations
o Account for significant portion of health o New regimen might be needed
Illness care cost 5. Acute Phase
- The human experience of symptoms and suffering, o Complications require hospitalizations
and refers to how the disease is perceived, live with Characteristics of Chronic Conditions o Require modification of activities
and responded to by individuals and their families 6. Crisis Phase
1. Has associated psychological and social problems o Life-threatening
Acute Chronic (disruption of roles, altered body image/lifestyle) o Needs emergency care
2. Usually involve many different phases over the 7. Comeback Phase
- Sudden in onset, with course of a person’s lifetime (remissions, o Recovery
S/Sx r/t the disx process - Continues indefinitely exacerbations, etc.) o Return to an acceptable way of living with
itself - Can appear suddenly 3. Keeping chronic conditions under control requires limitations
- Ends in a relatively or through insidious persistent adherence to therapeutic regimens 8. Downward phase
short time, either with process (turn q2h or else = bedsores) o Decline
recovery and - Have episodic flare- 4. One chronic disease can lead to the development o Does not necessary lead to death; depends
resumption of prior ups or exacerbations or of other chronic conditions, complications or on condition of patient and treatment
activities, or with death remain in remission acceleration of the disease condition (DM can lead regimens
with absence of Sx for to vision, cardiac, sexual and kidney problems) 9. Dying phase
long periods of time 5. Chronic illness affects the whole family (Care
giver role strain; disrupted family processes; Phenomenon of Aging
financial issues)
Impact of Chronic Illness to G & D 6. Major responsibility for the day-to-day Demographic of Aging
management of illness falls upon the shoulders of  Longer life spans
 Infancy through Adolescence chronically ill people and their families  Fastest growing age group is 85 years and over
o Very young child 7. Management of chronic conditions is a process of  Available health services
discovery
Care of Chronically Ill, Elderly Clients, and Hospice Care – Asst. Prof. Osel Sherwin Y. Melad L Y S H O I // P A G E | 2

Demographic Issues 7. Accidents 5) Free Radical Theory

1. Utilization of Health Care Resources 8. Alzheimer’s Disx o Free radicals damage cell
a. Older populations utilize health care 9. Kidney Disx
services at rates that are disproportionate to 10. Septicemia 6) Neuroendocrine Theories
their overall representation in the 11. Atherosclerosis o Changes in the brain and endocrine glands
population 12. Hypertension cause aging
b. They are hospitalized more frequently,
suffer from more chronic diseases, and use Other Characteristics of Elders 7) Apoptosis
more meds - Ethnicity o Apoptotic program is unregulated
2. Other Demographic Issues o Number of minority elders increasing o Precipitate disability and degeneration
a. Increasing diversity – ethnically, racially o Elder Hispanic fastest growing
and culturally subpopulation 8) Longevity and Senescence Theory
b. Poverty is a significant consideration - Socioeconomic o Factors that contribute to healthy aging:
o Women have longer life expect 1. Genetic
Top 8 Most Prevalent Chronic Conditions among Older o Men more likely to remarry 2. Physical environment
Adults o Educational level gradually increasing 3. Physical activity throughout life
1. Arthritis o Lower incomes 4. Consumption of moderate alcohol
2. Hypertension o Most live in community settings 5. Sexual activity persisting into
3. Heart Disease o Poverty level more likely when living advanced years
4. Respiratory Disease alone 6. Dietary
5. Diabetes Mellitus - Health 7. Social environment (status of
6. Cancer o Chronic health problems and disabilities wisdom and dignity)
7. Cerebrovascular Disease increase o Senescence – when death of older people
8. Atherosclerosis o 73% rate health as good, very good, or cannot be ascribed to a disease process –
excellent cause of death be listed as senescence
Top 10 Leading Causes of Hospitalization among Older o 20% report disability and most have o Illness – viewed as age-induced
Adults chronic disease
1. Heart disease Secret to long life?
2. Cancer Theories of Aging  “All things in moderation”
3. Cerebrovascular Disease 1. Biologic Theories  Longevity maximized by avoidance of excess
4. Pneumonia 1) Genetic Theories / Programmed Theory  Longevity may also be maximized by
5. Fractures o Life expect is pre-programmed avoidance of abstinence
6. Bronchitis o Cells divide at limited number of times  Jeanne Calment. Lived to 123. Died several
7. Osteoarthritis o Aging is a result of mutation of somatic years ago. Smoked cigars to 110. Drank
8. DM cells or alteration in DNA repair champagne until she died
9. Disease of the nervous system or sense organs mechanisms
(MS, cataracts, glaucoma) 9) Error Theory
10. Prostate Hyperplasia 2) Wear and Tear Theories o A stochastic theory of aging that ascribes
o Use and destruction aging to the accumulation of errors in the
Top 12 Causes of Death among Older Adults process of information flow from genes to
1. Heart disease 3) Immunity Theories proteins. The errors create faulty proteins
2. Cancer o Changes in the T-lymphocyte: increase (T- that do not function normally, resulting in
3. Cerebrovascular disease lymph fights off antigens or infections) impaired cell function and death.
4. Chronic Obstructive Pulmonary Disease (COPD)
and associated conditions 4) Cross-linkage Theories
5. Pneumonia and Influenza o Proteins become cross-linked 2. Sociologic Theories
6. Diabetes Mellitus
Care of Chronically Ill, Elderly Clients, and Hospice Care – Asst. Prof. Osel Sherwin Y. Melad
QUZ UNTIL CHARACTERISTICS ON TUESDAY
NEXT WEEK
August 4, 2015
- How interaction among and between older
adults help them achieve developmental tasks
(Ego-integrity vs. Despair)
1) Disengagement Theory (Cumming and Henry)
o Mutual withdrawal between elder and
elder’s environment
2) Activity Theory (Havighurst)
o Best way to age is to stay physically and
mentally active; adjust to the changes
3) Continuity Theory (Atchley)
o People maintain adult values, habits, and
behaviors as they age
o Adjustments to old age rests with the
ability of the person to continue life
patterns across a lifetime
4) Subculture Theory (Rose)
o Old people as a group has their own norms,
expectations, beliefs and habits
o They have the same culture thus they can
relate with each other
5) Age Stratification and Age Integration Theory
(Riley)
o This theory states that society age in
groups that change and influence each
other showing interdependence
6) Person-Environment Fit Theory (Lawton)
o Person’s competencies change with aging
thus affecting person’s ability to interrelate
with the environment
3. Psychological Theories
1) Erik Erikson
o Ego-Integrity vs. Despair (65-death)
o (-) sense of loss, contempt for others
o The greater the task achievement, the
healthier the personality
o Failure influences the person’s ability to
achieve the next tast
o Failure to resolve the crisis is damaging to
the ego
o In Erikson’s 8 stages, each stage represents
crucial turning points in the lifetime of a
person since birth
o Ego-Integrity = an acceptance of one’s
lifestyle and a belief that choices made was
the best possible choice that could have
happened; one is still in control of one’s
life, which is a life of dignity
o Despair = implies that the older person
feels dissatisfied and disappointed with
his/her life; if given another chance, the
person would live life differently
2) Robert Peck
o Ego Differentiation vs. Work Role
Preoccupation (occupational work is not
the basis for self-definition and worth)
o Body Transcendence vs. Body
Preoccupation (inner self, not the body, is
viewed as the basis for satisfaction,
happiness and morale)
o Ego Transcendence vs. Ego Preoccupation
(acceptance without undue fear and anxiety
of death; active involvement in a future
beyond morality)
3) Havighurst
o (65-75)
o Adjusting to
 decreasing physical strength and
health
 retirement
 lower fixed income
 death of parents, spouses and
friends
 new relationships with adult
children
 leisure time
 slower physical and cognitive
responses
o Keeping active and involved
o Making satisfying living arrangements
o (75 years and older)
L Y S H O I // P A G E | 3
o Adjusting to
 Living alone
 Possibility of moving into a
nursing home
 One’s own death
o Safeguarding physical and mental health
o Remaining in touch with other family
members
o Finding meaning in life
TECHNIQUES for GERIATRIC ASSESSMENT
 Prepare the environment to compensate
physiological and psychological changes
 Comfortable and warm, minimal exposure
 Straight backed chair (arms cushioned, not
too low)
 Exam table-padded, head part able to rise
 Noise free
 PA at the clients own pace
 Organize exam – minimize change in positions
 Establish non-threatening relationship
 Promote respect – address by their last name
 Allow to respond to questions
 Face the client while speaking
 If with hearing aid, make sure it’s functional
 Visually impaired – allow to wear glasses; use
visual cues
 Geriatric Team approach – recommended
 Include education on screening techniques
 Recognize cultural differences
ISSUES IN PHYSICAL ASSESSMENT
 Adjust for sensory deficits, with as little glare,
direct light, and background noise as possible
 Be attentive to older adult’s body language, which
may signify fatigue, anxiety, some degree of
cognitive impairment, or a need to void
 Employ an age-appropriate approach
 Eliciting a complete history from an older person
may take longer than for a younger person
How do you prepare for physical examination an older
adult with hearing impairment and severe COPD?
Care of Chronically Ill, Elderly Clients, and Hospice Care – Asst. Prof. Osel Sherwin Y. Melad L Y S H O I // P A G E | 4
What specialized equipment would you need in the room which may impair o Use of non-perfumed soap
and what adaptations to the environment would need to be  Changes in ambulation: o Use of emollient
considered? adnexal increase chance of
structures: pressure ulcers Dehydration
Older Adults Common Health Problems  Tenting of skin is normal with aging. Hand not a
 Injuries sebaceous and
sweat glands o Decreased reliable indicator of dehydration
 Chronic disabling illnesses  Use abdomen/forehead
 sweating
Drug use and misuse  Delirium is frequently caused by dehydration and
 Alcoholism o Decreased hair may accompany UTI
 Dementia growth
 Elder abuse o Decreased nail Pressure Ulcers
growth  Localized ulcerations of the skin or deeper
August 5, 2015 o Thinning and structures
graying of hair  Areas susceptible: occiput, ear, scapular, elbow,
AGE-RELATED ALTERATIONS  Changes in o Susceptibility to sacrum, ischial tuberosities, greater trochanter,
neurosensory infection medial condyle of tibia, fibular head, medial
Dermatologic function malleolus, lateral malleolus, heel
Structural change Clinical implication  Pressure of 70 mmHg applied for longer than 2
o Potential for injury hours can produce tissue destruction
 Thinning of o Increased because of  Take note of size, location, severity of pressure
epidermis wrinkling decreased ulcer
o Dry appearance sensation  Stages
o Uneven o Decreased number o Stage I – non-blanching macule that may
pigmentation of capillaries (thus appear red or violet (dilated blood vessels;
o Susceptible to diminished blood increased temperature); later on, skin
infection when flow) capillary occlusion = grey blue cyanotic
break occurs appearance
 Thinning of dermis o Stage II – skin breakdown as far as the
o Decreased dermis; necrosis or tissue death occurs
o Stage III – skin breakdown into the
elasticity subcutaneous tissue; formation of deep
 Decreased o Increased crater
vascularity wrinkling Nursing Implications o Stage IV – penetrates bone, muscle, or
o Vulnerable to 1. Skin care: gently stimulate non-reddened intact
joint
trauma skin sites with massage – avoid the use of hot water
*can cause infection; presence of pulse
and limit the use of soap (can thing the skin)
 Decrease amount o Decreased body 2. For immobile patients, consistent repositioning is
of subcutaneous temperature essential (q30min) – to promote circulation and Nursing Interventions for Pressure Ulcers
fat regulation 1) Prevent pressure ulcer development (meticulous
prevent bedsores
skin care and positioning
3. Keeping bed linens clean, dry and wrinkle free
2) Avoid elevation of head of bed greater than 30
o Sagging of skin, 4. Avoid prolonged exposure to sun
degrees (added weight and pressure to sacrum)
tenting (poor 5. Avoid long soaks in the bath tub
3) Reposition every 2 hours (to relieve and distribute
turgor and 6. Treatment for Xerosis: pressure on body parts)
mobility) o Drinking 2000 ml of liquid per day *pyarthrosis – pus formation in a joint cavity
o Decreased fat pads o Total body immersion in warm water (32.2 - 4) Use an alternating-pressure mattress or air-
on soles of feet, 40.6 C) fluidized bed
Care of Chronically Ill, Elderly Clients, and Hospice Care – Asst. Prof. Osel Sherwin Y. Melad L Y S H O I // P A G E | 5
5) Use normal saline for cleaning and disinfecting  ↓ accommodation Thyroid – stimulating  Secretion may
wounds  Blurred vision hormone (TSH) decrease slightly or
6) Apply wet-to-dry dressings as directed; or assist  Impaired color remain at previous
with surgical debridement discrimination levels
7) Cover the wound with a protective dressing (i.e. Vitreous body  Floaters and light
Hydrogel Dressings)  Decrease response to
flashes possible
8) Obtain wound cultures (to identify specific thyrotropin-releasing
microorganisms) and apply topical antibiotics Nursing Implications hormone (TRH)
1. Make sure objects are in the patient’s visual field  Decrease secretion
Ocular 2. Use large lettering to label medications Insulin  Adipocytes have
Structural Change Clinical Implication 3. Avoid glare decrease sensitivity to
Cornea  ↑ scattering of light 4. Use night-lights insulin
rays, causing a 5. Use red and yellow to stimulate vision  Decrease secretion
blurring effect 6. Mark the edges of stairs and curbs
 ↑ refractive power 7. Encourage yearly eye examination
Choroid  ↓quality of image 8. Encourage use of isotonic eye drops as needed Nursing Implications
reaching retina, encourage use of low vision aid such as magnifying 1. Encourage routine screening for elevated blood
causing acuity lens glucose both fasting and postprandial (after fasting,
changes 9. Avoid night driving eat/drink high carb, then measure)
Iris  Pupil size becomes 10. Wear eyeglasses, use sunglasses outdoors 2. Provide dietary education about a well-balanced
less refractive to light 11. Avoid glare of shiny surfaces diet
 ↓ ability to
accommodate to Auditory Endocrine
different light Structural Change Clinical Implication Hormone Alteration
intensifies Tympanic membrane  Possible impairment Renin  Decreased secretion
 ↓ vision acuity becomes thinner, less in auditory function  ↓ response to
Ciliary Body  ↓ nourishment and resilient, and may be  Deficit in equilibrium adrenocorticotropic
cleansing of lens and affected by sclerotic hormone (ACTH)
cornea changes/degeneration of Aldosterone  Decreased secretion
 ↑ eye dryness vestibular structures  ↓ response ACTH in
 Vulnerable to Ossicular chain may  ↓sensitivity to high presence of sodium
infection become calcified frequency tones restriction
Ciliary muscle  May change flexibility (presbycusis)  Vulnerability to
of lens Pinna becomes wider,  Changes in extreme
 Can cause acuity longer, and less flexible appearance of ear hypernatremia
changes Growth hormone  Decreased secretion
 ↓ peripheral vision Nursing Implications Glucocorticoid hormone  Clearance may be
 ↓ accommodation 1. Recommend hearing examination slightly ↓
Retina  Change in visual 2. Speak with low pitch voice, face person Parathyroid hormone  Secretion slightly ↑
acuity may occur 3. Use nonverbal cues Cortisol  ↓ response to ACTH
(color) 4. Speak clearly Glucagon  No alteration
 Night vision is altered 5. Reduce background nose
Decreased cellular  Laboratory values
Lens  Become less flexible,
response to many must be interpreted
point of focus Endocrine hormones carefully
becomes farther Hormone Alteration
(presbyopia) Thyroxine (T4)  Decreased secretion
Care of Chronically Ill, Elderly Clients, and Hospice Care – Asst. Prof. Osel Sherwin Y. Melad L Y S H O I // P A G E | 6

Decreased stress hormone  Decreased response to Structural Change Clinical Implication Structural Changes Clinical Manifestations
secretion stressors (internal and Enlargement of alveolar  Alteration in Mouth:  Decrease protection of
external) pulmonary function ↓saliva teeth and tongue from
Cardiovascular Elastic control ↓  ↓ sensitivity to bacteria
Structural Change Functional Change changes in levels of
↑ weight of heart and  ↓ cardiac output at rest O2 and CO2  Decrease taste sensation
vessels and exercise Closing volume ↑  Alteration in  Difficulty chewing and
 ↓ myocardial pulmonary function talking
contractile efficiency Loss of Cilia  Alteration in Stomach:  ↓ vitamin B12
↑ left ventricular posterior  ↑ systolic pressure pulmonary function ↓ gastric juice secretion, absorption
wall thickness (not greater  Nothing can trap including decrease in  ↓ protein digestion
than upper limits of bacteria before it
normal) reaches the lungs; air
intrinsic factors, peptic  ↓ iron and folic
and HCl acid digestion (may lead to
↓ early diastolic closure  ↑ left ventricular is not filtered
rates of mitral valve ejection time and pre- ↑ increased size and  Alteration in anemia)
ejection stiffening of trachea and pulmonary function Stomach:  Delayed emptying and
Replacement of pacemaker  ↓ responsiveness to central airways ↓ gastric motility maldigestion
cells by fibrous and catecholamines Calcification of chest wall  Leads to loss of Small Intestine:  ↓ Carbohydrate
connective tissue in SA and (epinephrine and alveoli ↓ mucosal surface area absorption
AV node (SA node = norepinephrine) Decreased cough reflex  ↓ ability to clear Changes in secretion of  Calcium malabsorption
normal pace maker)  ↑ ectopic activity infections and HCl acid, peptin, and
↑thickness of aorta and  ↓ maximal oxygen environmental (may lead to
peripheral arteries (occurs intake stimulants gastric juices osteoporosis)
independently of  ↓ Vitamin D absorption
arteriosclerotic disease)  Impaired fat absorption
Valves become more  ↑ stroke volume with Alteration in Pulmonary Function with Age: Colon:  Function remains intact
sclerotic progressive exercise  Decreased in forced vital capacity Mucosal atrophy
 May cause murmurs  Increase in residual volume Atrophy and muscle
 S4 heart sound may be  Increase in functional residual capacity
layer
present  Decrease in forced expiratory volume per second
Decreased response to  ↓ heart rate at rest and  Decrease in forced expiratory flow Changes in mucosal
beta adrenergic exercise  Increase in residual volume or total lung capacity glands
stimulation  Orthostatic blood Liver:  ↓ drug metabolism
pressure may occur ↓size  ↓ hepatic protein
Nursing Implications ↓ activity of drug- synthesis
Nursing Implications 1. Teach effective deep-breathing exercises metabolizing enzymes
1. Encourage regular blood pressure evaluation, 2. Teach measures to prevent pulmonary infections: ↓ size of hepatocytes
lifestyle modifications and medication avoid crowds during cold and flu season, wash with decrease
adherence, if indicated, for hypertension hands frequently, report early signs of infection,
vaccination proliferative activity
2. Encourage longer cool-down period after exercise
3. Encourage regular aerobic exercise: walking, 3. Avoid smoking and exposure to secondhand smoke ↓ splanchnic blood flow
biking, or swimming for 20 minutes at least 3x a 4. Teach pacing of activities Pancreas
week 5. Yearly influenza vaccine recommended ↓ number of secretory
4. Avoid smoking; low fat diet; weight control 6. Increase fluid intake acini and islets of
Langerhans
Pulmonary Gastrointestinal
Care of Chronically Ill, Elderly Clients, and Hospice Care – Asst. Prof. Osel Sherwin Y. Melad
Nursing Implications
1. Use of ice chips and mouthwash
2. Massage gums daily
3. Receive regular dental care
4. Eat small, frequent meals
5. Sit up and avoid heavy activity after eating
6. Limit antacids
7. Eat a high-fiber, low-fat diet
8. Limit laxatives; toilet regularly
9. Drink adequate fluids
10. Compute medication dosage properly
11. Monitor intake – nutritional needs
12. Have client sit upright when eating or drinking
13. Monitor for reflux and vitamin deficiencies
14. Observe for constipation and incontinence
Renal
Structural Changes Clinical Manifestations
Glomeruli  ↓ filtration in blood
 ↓ GFR up to 30-40%
 May contribute to ↓
clearance of meds
Tubules  ↓ tubule transport
 ↓ urine – concentrating
capacity
 ↓ sodium conservation
 ↓ concentration
mechanism in Loop of
Henle
 ↓ renal acidification
 Most potent diuretic:
Loop diuretics =
Furosemide (Lasix) –
but may cause
hypokalemia so you can
use Potassium-sparing
diuretics; Mannitol –
osmotic diuretic
Renal vasculature  ↓ blood flow
 ↓ efficienct in removal
of waste products
Connective tissue  ↓ bladder capacity
 ↑ residual volume after
voiding
Nursing Implications
1. Be aware that although creatinine level may be
within normal range, creatinine clearance may be
decreased. To obtain an accurate creatinine
clearance in an elderly person, the following
formula should be used:
[(140 − 𝑎𝑔𝑒)(𝑤𝑒𝑖𝑔ℎ𝑡 [𝑘𝑔])]
𝑚𝑔
[(72) (𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 [ ])]
𝑑𝐿
2. Drugs that are cleared through kidneys maybe
given in decreased dosage. Adverse effects and
toxicity must be closely monitored.
3. Incontinence is NOT part of normal aging
4. Causes: DRIP
D—delirium
R—restricted mobility, retention
I—infection, inflammation, impaction
P—polyuria, pharmaceuticals
5. Promote regular toileting schedules
6. Administer diuretics in early part of the day
Medication Considerations
1. Older adults may take lower initial dosages of Nursing Implications
drugs
2. Anti – HPN should be taken even if BP is normal
3. Aminoglycosides/aspirin: oto-nephrotoxic
4. Antibiotics: drug allergies
5. Changes in diet can impact medication: i.e. iron—
calcium; warfarin—green leafy vegetables;
tetracycline (can stain the teeth)—dairy products;
amiodarone—grapefruit juice
6. Monitor where medications are stored; nitrates—
dry, dark area, good for 6 months storage
7. Promote regular toileting sched
8. Administer diuretics early in the morning so as not
to disturb sleep
Nursing Implications
Common medications considered inappropriate for adults
L Y S H O I // P A G E | 7
1. Analgesics: propoxyphene (Darvon), meperidine
(causes tremors and seizures as CNS effect)
2. Hypnotics: diazepam, barbiturates except
phenobarbital (anxiolytics)
3. Antihypertension: aldomet (may cause adverse
CNS effect; bradycardia, orthostatic hypotension)
4. Antiplatelet: dipyridamole (Persantine)
5. Anticoagulant: ticlopidine (Ticlid)
*Old people lose their ability to metabolize the drugs
through the liver (oxidation)
August 11, 2015
Musculoskeletal
Age-related change Clinical Manifestations
↓ blood volume  ↑ incidence of micro-
fractures (esp. hip, wrist,
forearm, and vertebrae)
↓ size, number of muscle  ↓ lean body mass
fibers
Lean body mass  ↓ total body water
replaced by fat  Impaired ability to
compensate for fluid
and electrolyte changes
1. Encourage regular exercise (including weight-
bearing exercise)
2. Encourage calcium and vitamin D intake and
encourage decrease alcohol and nicotine use
(decreases absorption of vitamin D)
Reproductive Changes
 Female: Vaginal narrowing and decreased
elasticity; decreased vaginal secretions
 Male: decreased size of penis and testes
 Male and female: slower sexual response
1. May require vaginal estrogen replacement
2. Gynecology/urology follow-up
Care of Chronically Ill, Elderly Clients, and Hospice Care – Asst. Prof. Osel Sherwin Y. Melad L Y S H O I // P A G E | 8

3. Use a lubricant with intercourse  A systematic attempt to measure objective

 Generally do not performance in areas of daily living
Changes in Immune System change although total  Include: PADL (Physical ADL); IADL
 Decreased T-cell functioning Thyroxine (T4) protein may slightly (Instrumental ADL – shopping/cleaning)
decrease
Nursing Implications 1. ADLs are the basic self-care activities including:
1. Monitor for S/sx of infection (↑ WBC count -  Do not generally
normal = 4.5-11 T/cumm; fever; productive cough change with aging,  Mobility
etc.) despite decreasing  Dressing
2. First sign of infection --- maybe a fall… production of thyroid  Personal Hygiene
temperature pattern maybe lower than for younger hormone  Eating
adult with the same infection  Interaction of T3 and  Toileting or continence
T4  With brief mental status assessment tool
TYPICAL NDXs FOR OLDER ADULT  Exercise
1. Altered body temperature
2. Risk for aspiration Laboratory Values That Change With Normal Aging 2. IADL – not pertaining to self-care activities
3. Altered nutrition Value Implication
4. Fluid volume deficit Glucose  Slight increase  Shopping
5. Sleep pattern disturbance Creatinine clearance  Decreased  Household maintenance
6. Impaired tissue integrity  Using telephone
Serum uric acid  Slight increase
7. Altered comfort: Chronic pain  Paying bills or managing financial matters
8. Altered health maintenance Lactic dehydrogenase  No change or slight  Administering medications
(LDL) increase  Cooking
Laboratory Values That Alkaline phosphatase  Gradually increase  Laundry
Do Not Change With Normal Aging Total protein  No change or slight
Values Implication decrease Clinical Example
RBC  Anemia is not normal Total cholesterol  Slight increase or
Hemoglobin in older adults decrease possible  Changes in social situation may have a critical
Hematocrit (low density  Increase implications for overall functional status
lipoproteins)LDL  For example: an older man with no significant
BUN  Measure of renal HDL  Slight increase or health problems may experience a sharp decrease
Creatinine function do not decrease possible in functional status when his wife dies
generally change, Triglycerides  Slight increase  Although he is basically healthy, if he has never
although renal function
Triiodothyronine T3  Decreased cooked or done housework,
does with aging
Thyroid Hormone  he may find these tasks difficult
 Generally not an
TSH  No change or slight
accurate reflection of
increase AADL (Advanced ADL) Clinical Example
renal function
 Individualized
FUNCTIONAL ASSESSMENT  An older person who experiences functional
estimates of creatinine
decline r/t decreased visual acuity may no longer
clearance are more
Functional Assessment be able to drive
Liver function tests accurate
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 Mobility is affected, along with the potential for o Please DON’T FORGET THE Consideration of the ff.:
travel to recreational activities CLIENT!!!  Mood
 Increasingly, these needs, if met, require the  Anxiety
intervention of formal or informal support services The interrelatedness…  Self-esteem
 In this case, maintenance of maximal function  Depression
depends on continued participation in activities, Older adult with severe urinary incontinence (physical  Happiness and well-being
despite a decline in vision and ability to drive issue) that causes low self-esteem and embarrassment
(psychological issue) resulting in adult avoiding social Social Assessment
PSYCHOSOCIOSPIRITUAL ASSESSMENT outings with their friends (social issue).  To elicit the potential burdens and needs of family
caregivers
Psychosocial Function Assessment Psychological Assessment  Intervention is warranted when social isolation is
A. Cognitive Assessment
occurring, resources are inadequate and health
Requirement: 1. Folstein Mini Mental State Examination endangered, or domestic violence or abuse is
(MMSE) suspected
 Trusting relationship o Measures orientation (5,5); registration (3);
 Good communication skills attention and calculation (5); recall (3) and Assessment of Social Support
language (9)
 Interview questions Address the ff.:
o 30 point tool
 Purposeful observation  Social network
2. Short Portable Mentale Status Questionnaire
 Assessment tools  Barriers to social support
(SPMSQ)
Involves: o 10 items  Economic resources
o Test orientation, memory in relation to  Religious affiliation
 Mental status assessment self-care ability, remote memory and  Spirituality
1. assessment of affective function mathematical ability
Socio-Spiritual Assessment
 Assessment of social support Assessment of the Mental Status A. Support System
 Physical appearance Elements of Social Support:
Approaches  Motor function  Emotional
 Social skills  Assistance with task performance
 Continues over entire Nurse Patient relationship  Financial assistance
 Response to the interview
 Challenges—confused, in pain or fatigued  Advice and guidance
 Orientation  Formal support
 Be flexible
 Alertness  Informal
 Establish rapport
 Memory speech characteristics  Assess quality of care, learning needs, and
 Begin with introduction and general orientation to
 Calculation and higher language signs of caregiver burden
nurse role, purpose and future plans
B. Affective Assessment  Optimize caregiver knowledge and skills
 Therapeutic communication 1. Geriatric Depression Scale
 Be sensitive for signs of anxiety or distress o 30 item tool B. Financial Resources
 The art of listening—most important o Administered through self-report or as  Determine status and limitations
 Observe for nonverbal messages, feelings and interview  Health insurance
caregivers’ reactions 2. Beck Depression Inventory  Sources of monthly income
 Involve family members/caregivers as appropriate  Monthly expenses
Assessment of the Affective Function
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 Subjective opinion on the adequacy of  Associated physical and social changes  Inquire if patient has executed a living will
income  Look for signs of abuse and medical power of attorney
 Facilitate completion of documents if
C. Occupational and Education History H. Sleep Hygiene requested to do so (Advanced Directives)
 If currently employed  Reduced time in REM stage of sleep and o Living Will – written by the
 Type of employment before deep sleep (stage 4), increased wakefulness patient
 Reasons for retirement at night and fatigue at daytime o Medical Power of Attorney –
 Highest level of education patient designates someone else to
I. Sexuality decide
D. Living Arrangement  Assess: sexual preferences, past and
 Marital status current sexual activity, number of partners, M. Spirituality
 Living address and with whom changes in sexual activity, sexual  Finding meaning and purposefulness in life
 If satisfied difficulties, methods for protection and having a relationship with higher being
 Accessibility to services/support system  Intervention: education on sexual issues –
 Safety safe sex practices, alternative method/ Spirituality Assessment Guide:
 Accessibility to emergency assistance techniques for sexual expression, resources  Do you have a formal religious affiliation?
for help with sexual dysfunction  If yes, how active is your involvement?
E. Interest and Daily Routines  Are there any specific spiritual practices that are
 Involvement in social groups J. Cultural and Ethnic Background important to you?
 Recreational and leisure activities  Assess: place of birth, native language,  How important is your spirituality or religion as a
 Exercise folk med practices, practices unique to the source of support to you?
 If activity are altered, reasons for the cultural group  How important are your spiritual values and beliefs
change and how changes make them feel  Nurse should be cautious and not over in your decisions about your health care?
generalize individuals in a cultural group
F. Nutrition and miss the unique qualities of an MIDTERMS = Chronically Ill + Hospice Care
 Changes in body weight and appetite individual PASS WORKSHEET NEXT WEEK
 Usual food and fluid intake August 12, 2015
 Dietary preferences and restrictions K. Abuse and Neglect
 Food intolerance  1 million cases occur each year, Standardized Assessment Tools
 With whom and where meals are usually underestimate
eaten  Be nonjudgmental and begin with 1. Instruments should be chosen with the purpose and
 Chronic use of laxatives nonthreatening questions (avoid why time limitations of the assx in mind, along with the
 Problems with chewing questions) validity, reliability, and clinical relevance
 Memory impairment, depression, financial  Interview individual alone 2. Direct clinical observations that provide important
issues  Be alert of inconsistencies info about an older adult’s health and functional
 Nurse can make referrals to senior centers  Type of abuse? status
 Dental referral  When to be suspicious?
 Dietary supplement Area of Ex of assx What is tested
 Nutritional education (increase fluid L. End of Life Decisions concern instrument
intake)  Best obtained when individual is not Mental Folstein Mini- Tests orientation,
acutely ill Status Mental State memory, attention,
G. Alcohol, Drug and Tobacco Use language, recall
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Low score cognitive unimaginable ways. The pain derives not only c. Secondary gains – mentally retarded
impairment from each stigma-producing incident, but also persons will act in certain ways to get
Mood State Geriatric 30 affective items test from cumulative effect of numerous previous special treatment
Depression for depression incident with the latest one serving as a d. Resistance – when person speaks out their
Scale reminder of their inferior status” minds if not given proper health care
Functional Katz Index of Tests bathing, dressing, - “mark of shame or discredit” e. Passing – pretending to have a less
Ability Activities of toileting, transfer, - Perceived deficiency between expected and stigmatic identity
Daily Living continence, feeding, etc. actual characteristics f. Covering – attempt to make difference
(basic self-care) - When individuals fails to meet expectations seem smaller or less significant
Coded: independent, due to attributes that are different/undesirable =
assistance, dependent reduced from being accepted Stigma and Social Exclusion in Health Care
Functional Lawton Tests telephone usage, - Types of Stigma  Burden to society: ability or disability of the
ability Instrumental traveling, shopping, A. Stigma of Physical Deformity individual to cope with their problems
Activities of meal preparation,  Changes in physical appearance or  Intervention of family, society or state is frequently
Daily Living housework, medication, function viewed as failure of the individual
money B. Character Blemishes  Results:
Coded: Independent,  Occurs because of a behavior of a o Exclude indiv from equitable access to
Assistance, Dependent person housing, education, social support and
Dementia Set Test Tests ability to name up  Usually occurs in indivs with health services
Indicators to 10 items in 4 sets: AIDS, alcoholism, mental disease o Low self-esteem, poor social relationships,
(Dementia Fruit, Animals, Colors, and also with homosexual people isolation, depression and self-harm
is Towns (FACT)  Many believe that the infected
progressive Score maximum: 40 person could have controlled I. The Health Care System is not set up to
and behaviors that resulted in the provide services to the elderly
insidious) infection  Not equipped to serve the elderly
Social Zarit Burden Tests for feelings of  May be culturally derived population
Support Interview burden in care giving C. Prejudice  The insurance coverage has many
Alcohol CAGE Tests for alcohol abuse  When one group perceives features limitations
usage Michigan Tests for alcohol abuse of race, religion, or nationality of  Elderly do not work
Alcohol another group as deficient  Elderly depend in relatives
Screening Test compared with their own socially  Transpo, long waits, info
– Geriatric constructed norm  Resources are not allocated according to
Version Impact of STIGMA individual but according to the group
Falls Get Up and Go Tests balance and sway  Individuals with chronic conditions may not be
Assessment Test as risk for fall included in groups because others do not know II. The system exacerbates the problem of
how to act toward them stigma
Interventions for Common Old-Age Issues with  Responses of stigmatized individual:  constant message from HC workers
Evaluation a. Disregard – rejected; choose not to reflect regarding the elderly:
on or discuss; person with AIDS usually  High cost
1. Stigma b. Isolation – staying with others who one  Do not comply with treatment
- “A depreciating remark, cold stare, willful perceives as similar will give a person  A burden to HC facilities
disregard of a person’s viewpoint hurts in support
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 There is no return for the o Proposes that specific pain receptors o Meaning assigned to pain, how pain is
investment (nociceptors) project impulse over neural expressed, how treatment is accepted or
 Difficult to deal with pain pathways via brain and spinal cord perceived to be effective
 Require special time and are (A-delta and C fibers)
energy consuming B. Pattern theory Interventions for Dealing with Chronic Pain
o There is no pain-specific nociceptors and
III. Healthcare professionals are not trained to pain occurs from a combination of stimulus  Problem-solving process
provide for the special needs of older people intensity and central summation pattern of  Pharmacological management
 Training in disease and prevention impulses in the dorsal horn of the SG o Key concepts in administering
 Training is directed to pediatrics and C. Gate Control Theory narcotic/non-narcotic (to attain the best
regular adults o A gating mechanism in the dorsal horn of possible pain control with minimum side
 Problems of the elderly the SC permits or inhibits the transmission effects)
Ex, incontinence, senile dementia, of pain impulses o Meds (Goal: maximum benefit with least
Parkinson’s disx o Peripheral nerve fibers that synapse in possible harm)
- Unpleasant odors, bed ridden gray matter of the dorsal horn serve as gate  Narcotics
 Lack of knowledge by the health o If gate is closed, then pain impulses can’t  Non-narcotics
professionals reach the brain  Anti-depressant
 Lack of interest by the health  Non-invasive methods:
professional ACUTE PAIN CHRONIC PAIN o Cutaneous stimulation (massage, pressure,
 Respect and dignity are underestimated - Time limited from - Persists for a vibration, ice application, heat/cold, TENS
 Unable to demand own rights mins to weeks length of time o Distraction
- Subsides when (more than 3-6 o Relaxation (e.g. deep breath humor, simple
Common Problems healing occurs months) touch)
 Improper dosing, adverse reactions, misdiagnosis, - Usually controlled - Occurs at intervals o Imagery
overlook, dismiss as normal by meds for months or o Cognitive – behavioral strategies
- Can be tolerated years o Complementary/alternative therapies
Dealing with Stigmatized Individuals: Interventions knowing its just - Associated with o Involvement of the family
1. Process of changing attitudes temporary chronic
2. Developing a support group of one’s own and pathologies Social Isolation as a Nursing Dx
learning to cope with negative responses  Aloneness experienced by the individual and
3. Developing supportive others Problems and Issues of Chronic Pain perceived as imposed by others as negative or
4. Health care providers as adovcates threatening state
5. Develop a health care delivery with equitable  Under treatment by professionals  Critical Characteristics:
sharing of power and goals o Addiction a. Absence of supportive significant others
6. In service education for professional and non- o Physical dependence b. Verbalized feeling of aloneness imposed by
professionals o Drug tolerance others
7. Societal education  Effects of unrelieved pain c. Verbalized feeling of rejection
o Depression d. Others: apathy, seclusion, few/absence of
CHRONIC PAIN o Anxiety contacts
o Fatigue and sleep disturbance
Theories of Pain  Effects if culture to pain Counteracting Social Isolation
A. Specificity Theory  Aim:
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a. Increase he moral authority or freedom of failures; indiv has not come to terms with  MS
choice to isolate future self; regretful person  Lifestyle
b. Increase social intx at the level acceptable to d. Salvaged self – indiv attempts to  CVD
them describe self as worthwhile; accepts the  DM
c. Use recognizable strategies that are validated fact that he/she has a chronic disease;  Iatrogenic factors – effects of meds
with pt., like reducing particular isolating where the person usually seeks health  Pain and lack of mobility aids
behavior care
B. Integrate Culture in Health Care Effects of Immobility
Assessment of Social Isolation o Provide culturally similar providers Cardiovascular Metabolism
 Guide people, don’t force interventions o Education on cultures - Hypotension - Dec metab rate
 Observe 3 distinct features: o Provider approach each person with - Inc. workload of - Impaired glucose
o Negativity respect and dignity and use of authentic heart tolerance
o Involuntary, other-imposed solitude sensitive inquiry into clients belief and - Thrombus - Negative nitrogen
o Declining quality and # within isolate well-being formation balance
social network C. Respite
 Often accompanied with anxiety, desperation, self- o Pause/rest (patient and caregivers) Interventions for Client with Altered Mobility
pity, attempts to fill a void (overeating, substance o To relieve care givers for a period of time  Physical activity
abuse) so that they may engage in activities that o Increase activity in bedridden
help sustain them or their loved ones  Adequate nutrition high in calories
Assessment Result o Shopping, massage, recreation, movie-  Pain control
 Client is a lifelong isolate, future isolation is watching at home or downtown or  Aids for sensory impairment
desired and comfortable lifestyle wherever  Psychosocial interventions
o Intervention: remain available, observant D. Support Groups  Management of equipment
but noninterfering o For people with the same condition  Reduce environmental barriers
 Client becomes isolated and needs relief (Alcoholics Anonymous)
o Intervention: be constructed and E. Spiritual Well-Being Assessment of Fatigue
consistent with need and history F. Rebuilding Family Networks  How would you describe experience with fatigue?
G. Communication Technologies  How long have you been bothered with this
Management o Telephone  Has fatigue had any effect on your relationships
A. Self – Identity o Computers  What time does it occur?
o Chronically ill needs to develop new sense of o Touch (individualized response; pets may
self, consistent with disabilities be utilized) Managing Fatigue
o Have to deal with new body demands  Energy-conservation and exercise strategies
o Hierarchical Identity: Mobility and Aging o Setting priorities
a. Supernormal identity – attempts to  Number of muscle fibers – reduces in strength and o Delegating
participate more intensely than normal, endurance o Planning
despite limitations  Decline in chondrocyte fxn – reduced ability for o Pacing resting
b. Restored self – when expectations will repair  cartilage surface deteriorate  Maintain one’s role as a spouse
eventually return to previous self despite  Collagen fibers inc. in diameter  Assess factors that can be modified to reduce
chronic illness fatigue
c. Contingent personal identity – defines Other Associated Changes with Aging  Cancer patients: talking about experiences and
oneself in terms of potential risk and  Neurologic Strokes (CVA) receiving explanations about their symptoms
Care of Chronically Ill, Elderly Clients, and Hospice Care – Asst. Prof. Osel Sherwin Y. Melad L Y S H O I // P A G E | 14

 Explore ways to elevate mood

 Nutrition, small frequent meals

Quiz LAB VALUES  assessment tools