Geriatric

Nursing
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 HOWTOUSETHISCOURSE

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 TABLEOFCONTENTS

HowtoUseThisCourse 2

CourseObjectives 4

Introduction 5

ChapterITheNursingProcess:GeriatricAssessment 10

ChapterII PsychologicalAssessment 31

ChapterIII PhysicalAssessment&RecordingtheFindings 42

ChapterIV TheNursePatientHelpingRelationship 55

ChapterV TheCharacteristicsandCrisisofLaterMaturity 64

ChapterVI DrugTherapiesfortheElderlyClient 82

References 85

CourseTest 87

 Course Objectives

Uponcompletionofthisprogram,eachparticipantwillbeableto:

1. Definetheterm,LaterMaturityratherthanusingthetermOld
Ageasthelastdevelopmentalstage
2. Nameanddescribethestereotypesandattitudesusedin
describinganddealingwithelderlyclients
3. Explainhowpersonalvalues,attitudesandfeelingsaboutthe
elderly,willaffectthebehaviorofpeopletowardtheelderly
4. Nameanddescribeatleasttwomethodsofeffective
communicationsthatallowthenursetoobtainagoodnursing
historyduringtheassessmentprocess
5. Nameatleasttwointerventionsthatcanbeusefulfor
individualizingthenursingcarefortheelderlyclient
6. Nameanddiscussatleasttwocharacteristicsofthehelping
relationship
7. Nameatleasttwobehaviorsthatindicatesahelpingrelationship
fortheelderlypatient
8. Nameanddescribeatleastfivephysicalchangesthatcommonly
occurinlaterlife
9. Nameanddescribeatleasttwowaysinwhichthenursecan
intervenesupportively,usingself,environmental,orphysicalaids,
tohelptheseniormaintainorregaincognitivecompetency
10. Nameanddescribeatleastonemethodofexploringthe
meaningofdeathandpersonalattitudestowarddying,deathand
themaintenanceoflife

 Introduction

Understandingtheagingprocessprovidesthenursewithanimportant
perspectiveonthecareoftheelderlypatient.Thelongestliving
humanstoday,livenolongerthantheydidcenturiesago.Maximum
humanlifespanisapproximately100yearsofage.Thishasnot
changed.However,theaveragelifeexpectancyhasincreased
dramatically.Theaveragelifeexpectancyin1900was47yearsold.In
1990theaveragelifeexpectancyisnow75yearsold.In1900only
about4%ofthepopulationwasage65yearsorolder.Todayabout12
13%ofthepopulationisover65.Withinthenext50years,theover65
populationisexpectedtodouble.

Oneoftheprimereasonsforthisincreasedlifeexpectancyisthe
dramaticincreaseofinfantsurvival.Theadventofgoodprenatalcare
andimproveddeliverytechniqueshavegivenpeopleinourcountrya
tremendousadvantageatthestartofourlives.Thereareother
contributingfactorsaswell.Bettersanitation,betternutrition,better
standardofliving,bettermedicalcareandpreventionandtreatmentof
diseaseshaveallcontributedtoourlongerlifeexpectancyinthis
countryandaroundtheworld.Allthesefactorscontributetoabetter
survivalrateforchildrenborninAmerica.Oncethesechildrenreach
adults,theyaremorelikelytogettooldage.

ThesemajorreasonsforthelengtheningoflifeEXPECTANCYare:
a. Betterprenatalcare
b. Betterdeliverytechniques
c. Bettermedicalcare
d. Betternutrition
e. Betteruseofpreventativemeasures
f. Agenerallyhigherstandardofliving
g. Moreleisuretime

 h. Researchinmanyareasthatcontributestowardmakinglifemore
comfortableandhealthier(Murray1980)

Inaddition,societysattitudesandtheattitudesofeachofustoward
thosewhohavelivedlongenoughtobecomeapartoftheaged
statisticsarealsoimportant.Theseattitudescannotbesoquicklylisted
andresolved.Themedicalandnursingprofessionshavenotbeenquick
toplanfor,orimplementhealthcaretomeettheuniqueneedsof
peopleinlatermaturity,thenotsoold,andtheveryold.

Oneoftheobjectivesofthisprogramistostimulateyou,thenurse,to
lookatthepersonandfamilyinlatermaturitywithamorepositiveyet
realisticattitude.Thisobjectiveincludesstimulatingyoursensesof
empathyandcompassion.Empathyandcompassionforelderlyclients
arefosteredbyyourunderstandingoftheagingprocessandallthe
socialattitudesandstressorsimposedupontheperson(Murray1980).

Rememberhowveryimportantyou,thenurse,aretotheelderly
personwithwhomyouwork.Throughanappraisalofyour
involvementwiththepersonlivingthroughthelatdevelopmental
stage,youwillgrowinselfknowledge,selfacceptanceandfulfillment.
Thesequalities,withindicateapersonaldepthandintegrity,maythen
becomethebasisforfurthercompassionatecaringandknowledgeable
nursing(Murray1980).

LaterMaturityreferstothelastdevelopmentalstageinlife.Thisstage
beginsafterretirementage,usually6570yearsofage,inthiscountry.
Traditionally,thiserahasbeencalledoldage.However,this
encompassessuchalargetimespan.Therefore,somepersonsreferto
theseagesof65to75astheYOUNGOLDAges.TheOLDOLDAgesare
consideredtheyearsof75andgreater.Theendstageoflatermaturity
isstereotypedbysomeauthorsasbeingaperiodofdependencyupon

othersforassistanceinmeetingbasicneeds.Thisstereotypeoften
persistsandiswhatsomepeoplerefertoasoldage.

Thedefinitionsofthetermsold,agingandagedarepertinentto
latermaturity,butnotnecessarilyinthesameinmeaning.Oldis
defined(Murray1980)ashavingexistedforalongtimeorbeing
advancedinyears.Agedisdefinedasthatpointinthelifespanofa
personwhenchangesofagingmarkedlyinterferewithfunctioning.
Agingiscommonlythoughtofasthosechangesassociatedwith
decliningfunctionafterthepersonreachesmaturity.

TheworksOLDandAGEhavedifferentmeaningstoeachofus.

Thismeaningdependsupon:
a. Ourselfimage
b. Personalpatternsofadjustment
c. Emotionalconflicts
d. Pastexperienceswithelderlypersons
e. Socioculturalbackground
f. Ethnicbackground
g. Religion
h. Personalage

Tothe4yearold,20mayseemancient.Totheteenager,30mayseem
old.Tothe30yearold,50beginstolookyounger.Tothe75yearold,
oldmeansanyoneover80.TotheaveragewhiteAmerican,oldis
associatedwithretirementfromthejob.TotheMexicanAmerican,50
yearsmaybeconsideredold.Thewordoldhasnegative
connotationstomanypeopleintheUnitedStates.However,insome
cultures,theoldareevenreveredasveryspecialandknowledgeable.

Nootherdevelopmentalera(theelderly)issorigidlystereotyped.In
nowaycanallolderpeoplebealike.Justasalltoddlers,all
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adolescents,orallyoungadultscannotbeconsideredtobealike.
Seniorsmustbeperceivedtobeindividual,eachhavingawiderangeof
personalitycharacteristics,distinctpatternsofcopingwithlifeand
uniquerelationshipstoothers(Murray1980).

Inordertoperceivetheseniorasauniqueperson,youmustconsider
yourpersonaldefinitions,values,attitudesandfeelingsaboutoldage
andaging.

Whatdoesoldagemeantoyou?

Whatdoyouvalueorconsiderimportant:Beauty,youthandstrength?

Ordoyouconsiderwisdomthoughtfulness,experienceandageas
important?

Whatisyourmentalsetorattitudetowardelderlypeople,whichin
turnaffectsyourbehavior,orovertreactions?

Whatisyourfeelingorsubjectiveresponsewhenyouarewiththe
elderlyperson?

Doyoufeelpleasureorimpatience,respectorrepugnance?

Doyoufeargrowingoldordoyoulookforwardtolatermaturity?

Whenyouinitiallycareforelderlypeople,youmayfeelafraid,
disgustedorimpatient.Thesefeelingsarenotatallunusual.Itis
importantthatyoufacethesefeelingsandtrytounderstandyour
valuesandattitudes.

Certainly,youwillnotlikeeveryoldpersonthatyoucarefor.However,
youwillbeamoreeffectivecaregiverifyouarenotsad,angryator
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disgustedwithhimorheronlybecauseheorsheisold.Youcouldalso
bemoreeffectiveifyoucanappreciatetheirstrengthsaswellastheir
limits.Respecttheelderlypersonsimplybecauseheorsheisahuman
beinglikeyourself.Accepttheirlimitsandperceivehimorherasa
uniqueperson.Heorshewillthenrespondtoyouracceptance.
Understandandrespecttheelderlyperson.Heorshewillthenshare
moreofthemselveswithyou.Thissharingisgratifyingandwillenable
youtogiveevenmoreofyourself.Ahelpingrelationshipwillthen
develop.Itcanbearelationshipinwhichbothofyoumature(Murray
1980).

 CHAPTER I

THE
NURSING PROCESS
AND
GERIATRIC
ASSESSMENT
THE NURSING PROCESS
ASSESSMENT:

Intheassessmentprocess,dataabouttheperson,thefamily,thegroup,orthesituationareobtained.
Thisassessmentisaccomplishedbymeansofastuteobservationsandexamination.Alsousedin
assessmentare:purposefulcommunicationandtheuseofspecialskillsandtechniques.Thisdata
gatheredbythenurseandotherhealthteammemberscanbeusedtogainabroaderperspectiveabout
theelderlyperson.Theobjectiveandsubjectivedataarecriticallyanalyzed,interrelatedand
interpretedthroughtheuseofinference,knowledge,personalorhealthcareteamexperience,records
andavarietyofothersourcesasindicated.Nursingjudgmentsaremadebasedonthisextensive
assessmentinformation(Beland1975).

Firstlevelassessmentisdoneoninitialcontactwiththeelderlypersonorfamilytodeterminethe
perceivedhealththreat,theabilitytoadapttothethreatandimmediatenecessaryactions.Second
levelassessmentcontinuesthroughoutthetimeofcontactwiththeperson.Itaddsdepthandbreadth
tounderstandingofphysical,emotional,mental,spiritual,family,social,culturalcharacteristicsand
needs.Thismorecomprehensiveviewofthepersonenablesyoutoplanandgivecarebettersuitedto
thewholeindividualorsituation(Bower1972).

Anursinghistoryformorassessmenttoolisanorganizedmethodofrecordingtheinformationobtained
inthefirstandsecondlevelassessments.Itisdistinctfromthemedicalhistoryinthatitfocusesonthe
meaningofillnessandhealthcaretothepersoninsteadofprimarilyonpathology.Theformservesasa
guidetoobtaininformationthatdoesnotrepeatdatacollectedbyotherhealthcareteammembers,
althoughitmayinclude,aspectsofthemedicalorsocialhistorythatispertinenttonursingcare.

Thenursingassessmentincludingthenursinghistoryprovidesacompositepictureofthepatient.Other
healthcareteammembersmayusethisasanintroductiontothepatient.

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Althoughtheformused,andthekindofinformationcollectedmustbeadaptedtoyourindividualwork
settingandyourclientele,Bowerstatesthatthenursinghistoryshouldincludethefollowing
information:

1. Previousexperiencewithillness,hospitalization,healthagencies,nursesandnursing(alsothe
meaningoftheseexperiences).
2. Intellectualunderstandingandinterpretationofhealthproblems,diagnosticregimen,
treatmentregimen,specificquestionsorconcerns.
3. Educationallevelandintellectualcapacity.
4. Languageusageandcommunicationpattern.
5. Usualpatternsofliving,health,religionandrecreationpursuits
6. Occupationalandsocialrolesandresponsibilities.
7. Developmentalstatusandlevelofbehavior
8. Usualbehaviorpatternsinthepresenceofstressorcrisis
9. Closerelationshipswithothers;abilitytohelpinthissituation.
10. Expectations,goalsandneedsrelatedtohealthcare.

Thenursinghistoryshouldalsoincludedailypreferencesandidiosyncraticpatternsofliving.For
example,manyelderlypersonsdrinkprunejuiceoraglassofwateronarisingeachmorning.Ifthis
patternisnotcontinuedafteradmissiontothehospitalorresidence,thepersonmayfeelasenseof
loss.Heorshemaybecomeirritableordepressed.Adheringtotheirestablishedpatternmaypromote
theirwellness,physically,andtheirfeelingofbeingcaredfor.Suchpreferences,minortous,canonly
beobtainedthroughacarefullyobtainednursinghistory.

Youmaythinkthatobtainingalengthyassessmentandnursinghistoryistootimeconsumingandis
impractical.However,itisavitalactivityforthepurposeofindividualizingpatientcare.Anursepatient
relationshipisbegunduringtheassessmentprocess.Assessmentconveysinterestandconcerntothe
patient.Italsoestablishesasenseoftrustfromthepatient.Anursingdiagnosisandrealisticcare
objectivescannotbeformulatedwithoutinformationobtainedinanursinghistoryorwithoutpatient
involvement.

Inaddition,thelaststepofthenursingprocessevaluationwillbedifficulttocompleteunlessthereis
baselinepatientdata.Everynursingunitshouldhaveaformalguideforperforminganursing
assessmentandhistory.Allofthenursesshouldbeinvolvedinthedevelopmentofthetool.
Developmentoftheassessmentandhistorytoolincludestrialusageandrevisionssothatthetoolwill
beusefulindailypractice.(Seeassessmentguideattheendofthissection.)

Goodcommunicationsskillswillhelpyoutoobtainassessmentandnursinghistorydata.Useopen
endedstatements.Indicateyourobservationoftheseniorsbehavior.Indicateyourlevelof
understandingoftheirimpliedcommunication.Silencemayalsobetherapeutic.Letthesenior
elaborateonanswers.Beattentivetothenonverbalcommunicationanditspossiblemeaning(s).

Thesebehaviorsonthepartofthenursecanhelptoaddtothetotalamountofinformationgatheredin
theinterviewprocess.Donotaskabarrageofdirectquestions.Manydirectandpointedquestionswill
tendtostifletheseniorsexpression,resultinginsuperficialandbriefanswers.Theinterviewerwhois
tooactiveobtainslesspertinentdata.Anassessmenttoolisnotmeanttobeusedasaprobe.

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Askquestionsrelatedtowhattheseniorissayinginordertofillinthegapsofneededinformation.In
thisway,youmayobtaininformationthatwasnotanticipated,butmightturnouttobesignificant.
Someinformationmightbetterbecollectedbydirectobservationofthesenior.Informationsuchas
theirinterpretationofrealitymightbeobserved.Theirabilitytoabstractmightbeobservedinreallife
situations.Youwillprobablynotbeabletofillinallthespacesontheformonthefirstinterviewwith
theclientorthefamily.Youwillprobablygetmoreaccurateinformationifyouusetheassessmenttool
asaguideoveraperiodofseveralvisits.

Inseveralvisits,youwillbebetterabletodeterminepatternsofbehaviorandtheusualhealthillness
statusofthesenior.Drawingconclusionsonthefirstinterviewdatamaynotbeveryaccurate.Several
interviewswilladdreliabilityandcompletenesstothedatacollected.Inaddition,themoreskillfulyou
areasacommunicator,themorereliableyourdatawillbeasthebasisforcontinuedcare.

Cultural Perspectives on Aging (Gioiella 1985)

BlackAmericans

ThereareseveraldifferentculturalgroupsrepresentedwithBlackAmericans.Thepopulation
descendedfromAfricansbroughttotheU.S.asslavesisdifferentfromthemorerecentimmigrants
fromAfricaandtheCaribbeanIslands.Notallstudiesdifferentiateamongthesegroups.Ingeneral,the
BlackAmericanreportsmoreillnessesthanWhiteAmericansandputsoffgettingcare,especiallycareof
theteethandeyes.TheBlackAmericanequateshealthorwellnesswithbeingabletolabor
productively.

AstudyofdietarypatternsofurbanelderlyrevealedthatBlackshadsignificantlypoorernutrition.
Maleshadasignificantlypoorerdietthanfemalesregardlessofrace.Thesameresearchersfoundthat
eventhoughelderlyBlackshadpoorernutritionandlowerincomethanelderlyWhites,theyfoundno
differencesinlifesatisfaction.Bothgroups(andelderlyMexicanAmericans)reportedthesame
satisfactionwiththeirlives.

AnotherstudyonphysicalfunctioninWhiteandBlackelderlyrevealedthatBlackshadgreater
decreasesinmobilityandselfcarecapacitythanWhites.BlackwomenhadmorelimitationsthanBlack
men.BlacksalsohadtwiceasmuchtimespentinbedduetoillnessthantheWhiteelderlysubjects.

Hispanics

ThisculturalgroupincludesbothMexicanAmericansandPuertoRicans.Manyvaluesandbeliefsare
similarinbothcultures.SomeHispanicsviewillnessashavingsocial,spiritualandphysicaloriginsand
wellnessasaholisticbalanceandequilibriumbetweentheindividualandtheuniverse.Illnessmaybe
duetofright,apunishment,orsupernaturalinfluences.Rituals,prayersandmagictodealwiththeevil
eyeareusedinhealingbytheespiritualistaorthecurandero.

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TheHispanicmayalsouseherbs,massageandwarmbathstorestorebalancebetweenhotandcold,dry
andmoist.Illnesses,foodsandtreatmentsaredescribedashot,cold,ormoistandmustbecombined
appropriatelybythecaregiver.

TheGrandparentorGodparentrollisimportantintheHispaniccultureandoftenisanimportantrole
fortheelderlyfamilymember.Theextendedfamilyisalsomorecommoninthisgroup,although,
erosionofthisfamilystructureisagrowingphenomenoninyoungergenerationsofHispanics.

ChineseAmericans

TheChineseandtosomedegree,otherAsians,haveasystemofbeliefsabouthealth,illnessandthe
practiceofmedicinethatdiffersgreatlyfromWesternbeliefsandpractices.EmphasisintheEastison
prevention,maintainingabalancebetweenenergysystemsinthebody,theYangandtheYin.

TheChinesehavetheirowndiagnostictechniques,avoidintrusiveproceduresthattheybelieveaffect
thewholenessofthesystemandavoiddrawingbloodifpossible.Herbs,acupuncture,meditation,
massageanddietareallusedtotreatillness.Healersplayanimportantroleinhealthcare.

TheelderlyhaveanimportantroleandgreatrespectinAsiancultures.Childrenareexpectedtocarefor
theirelders.SomeofthistraditionispresentinAsianimmigrantsintheUnitedStates.However,the
elderlymayexpectmorethantheirmorewesternizedchildrenorgrandchildrenarepreparedtogive.

NativeAmericans

HealthbeliefsandpracticesofNativeAmericansvaryfromtribetotribe.Healersareimportantin
many,especiallyifthetriberelatesillnesstoevilspirits.Ingeneral,NativeAmericansbelievethat
healthisGodgivenandreflectslivinginharmonywiththeuniverse.Manytraditionaltreatments
includingdiet,massage,herbsandritualsareused.

InsomeNativeAmericantribestheelderlyareconsideredasourceofwisdomfortheyounger
generation.Directquestioningoraskingtheindividualtorepeatinformationisconsideredamarkof
disrespect.

WhiteEthnicAmericans

Verylittleisknownaboutthehealthbeliefsandpracticesoftheelderlywhocontinuetoidentifywith
Irish,Italian,Polish,GermanorotherEuropeancultures.Crossculturalstudiesdorevealdifferencesin
expressionofpain,differencesindiet,differencesinlifestyleanddifferencesinperceptionof
importanceofcertainsymptoms.Anotherstudylookedattheuseofformalsocialsupportsystemsby
whiteethnicaged.Itfoundthatuseinthisgroupwasgenerallylow.Family,friendsandchurchgroups
weremorelikelytobeusedforassistance.

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ImplicationsofCulture

Manyclientsmayretainfolkhealthpracticesaslinkstotheirculturalheritageinanefforttomaintain
identity.MostnursesintheU.S.aresocializedintothescientificmodelofhealthcare.Aconflictof
beliefsandpracticesmay,therefore,arisebetweenclientandnurse.Certainlynursesshouldnot
abandontheirownrespectforscience;however,respectforthealternativehealingmethodsand
traditionalhealthpracticesshouldbemaintained.

Toovercomeculturalbarrierstohealthcare,useofethnicproviders,ethnicorganizations,native
languagesandfoodsshouldbeconsideredbythenurseinprovidingcare.

STATEMENTOFNURSINGDIAGNOSIS:

Onceasufficientamountofinformationhasbeencollected,theinformationcanbeanalyzedand
interpreted.Next,thenursecanformulateanexplicitstatementaboutthepresentingproblemor
unmetneeds.Theseunmetneedscanthenbeaddressedbynursingcare.

Thetermdiagnosismeanstostateadecisionoropinionaftercarefulexaminationandanalysisoffacts
inasituationorcondition.Thetermdiagnosisisnotlimitedtomedicalconditions.TheNursing
Diagnosisisadescriptionofbehavioratvariancewiththedesiredstateofhealth,acommonlyrecurring
condition.Italsomeansunmetneedsthatinterferewithhealthandadaption,orthepresentor
anticipatedproblemordifficultyexperiencedbythepersonorfamilywhichisamenabletonursing
intervention.

Thediagnosticstatementorlabelprovidesaguidelineforinterventionandindicatesprognosis,
potential,ordesiredoutcome(Murray1980).Nursingdiagnosesdonotlabelmedicalentities.They
refertoconditionsthatcanbehelpedbynursingaction.Nursingdiagnosesthatmaybeapplicableto
thepsychologicalandphysicalstatusoftheelderlyarelistednextinthissection.

NursingDiagnosesapplicabletothepsychologicalandphysicalstatus:

a. Anxietyoragitation
b. Confusion
c. Emotionalorsocialdeprivation
d. Disengagement
e. Mourning
f. Impairedadjustmenttocrisis,stressortheagingprocess
g. Maladaptivefamilyprocess
h. Alteredlevelofconsciousness(lethargy,stupor,coma)
i. Lackofunderstanding
j. Noncompliancewithtreatment
k. Pain
l. Alteredabilitytoperformactivitiesofdailyliving(selfcare)
m. Impairedmobility

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 n. Impairednutritionhydrationstatus
o. Impairedintegrityoftheskin
p. Impairedsensoryprocesses(blindness,deafness,paresthesias)
q. Negativeselfconcept
r. Impairedverbalcommunication(aphasic,mute,asocial)
s. Suspicion
t. Withdrawal
u. Insomnia

Thisabovelistisnotcomplete.Variousmedicalproblemswouldalsogeneratepertinentnursing
diagnoses(physicalandpsychological).

FORMULATIONOFPATIENTCAREANDGOLASANDPLANOFCARE

Afterassessmentandstatementofnursingdiagnosis,variousnursingactions,approachesorsolutions
areconsideredinviewofthenatureandprobablesourceofthepersonsunmetneeds.Atthispoint,
patientcaregoals,statementsaboutapredictedordesiredpatientoutcomecanbeformulated
cooperativelywiththepersonorfamily.Shorttermgoalsareindividualizedtotheperson,arederived
fromthediagnosisandcanbeaccomplishedinashortspanoftime.Longtermgoalsarefuture
orientedandstatetheultimatedesiredresultofnursingintervention(Murray1980).

Priorityofgoalsisaffectedbythefollowingcriteria:

1. Nursingdiagnosisisidentifiedincollaborationwiththeseniororfamily.
2. Severityofhealthproblemorseniorslifesituation.
3. Potentialforrecoveryorsusceptibilitytorelapse.
4. Amountoftimeneededbytheseniororthenurse.
5. Receptivitytonursingcarebythesenior.
6. Costintermsofmoneyorenergytothesenior,nurse,agency,society.
7. Demandsofexternalconstraintssuchasagencypolicies,legalfactors.

Shorttermgoalsfortheelderlyhospitalizedpatientmightincluderelieffrompainorinsomnia.The
longtermgoalmightincludeincreasedmobilityorselfcare.Shorttermgoalsfortheelderlyclient
admittedtothenursinghomemightincludeorientationtothefacilityanditspolicies.Longtermgoals
mightincluderesolutionofthecrisisofdeathofaspouseandadmissiontothenursinghome.

Whengoalsareformulatedandprioritiesset,thedetailsofthemeetingofthesegoalscanbewrittenin
thenursingcareplan.TheNursingCarePlanisarecordsummarizingtheinformationobtainedfromthe
assessment.TheCarePlanisneededinordertoproperlyimplementappropriatenursingcare.Itisalso
aguidetomeetingspecificgoalsfortheelderlypersonorfamilyatagiventime.

15

Thewrittenplanincludes:

a. Thepatientsneedsandproblems.
b. Patientcaregoalsandpriorityinreachingthem.
c. Nursingordersortheapproachesoractionsthathavebeenselectedfromtheavailable
alternatives.
d. Expectedbehavioraloutcomes.
e. Evaluativecriteriatomeasureactions.

Caremeasuresprescribedbythephysicianandgeneralmeasuresdeterminedbythepersonssituation
oragencypolicyarealsoincludedintheplan.Thecareplanisbegunwhentheseniorisadmittedtothe
agency.Itmustbeupdatedthroughouthisorherstayasmoreinformationisobtainedorastheir
conditionchanges.Thenursewhofirstcontactsthepersonisusuallyresponsibleforbeginningthecare
plan.Thereafter,allnursingpersonnelshouldbeencouragedtowriteobservationsandcare
suggestionsonthecareplan.

Onlythencanthefollowingpurposesofthecareplanberealized:(Bower1972)

1. Tocommunicateinformationaboutthepersonorfamilyandappropriatenursingactionsor
approaches.
2. Toprovideindividualizedandcomprehensivecare.
3. Toprovidecoordinationandcontinuityofcare.
4. Tofacilitateongoingandaccurateevaluationofcare.

Thenursingcareplanwillbeusedforalongperiodoftimeinthenursinghome,residentialcenterfor
theagedorextendedcarefacility.Sincehospitalstaysareextremelylimitedinduration,boththe
nursingcareplanandthenursinghistoryarejustifiedforshorttermcareintervalsandshouldbecomea
permanentpartoftheseniorsrecord.

Itwouldthenbeavailableforunderstandingthepatientonfutureadmissionsandforfurthercare
planning.Additionally,thecopyofthecareplan(andhistory)shouldbesentwiththeseniorupon
transfertoanotheragency(Murray1980).

INTERVENTION

Interventionreferstoalloftheactionsthatyouengagein,aswellastheapproachyouuse,topromote
thepatientswellbeing.

Interventionincludes:

a. Verbalandnonverbalcommunications.
b. Aidrecoveryoftheclient.
c. Yourapproachandreactionstothepersonasyoupromoteandmaintainbiopsychosocial
health.
d. Visibleactions.

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 e. Comfort,protection,enhancedstability.

Interventionoccurswhenyoupreventharmorfurtherdysfunctionorassisttheseniortofunctionas
effectivelyaspossiblewithinthelimitsimposedbyhiscondition.Manytasksdoneunwittinglyare
nursinginterventionsandshouldbedefinedassuchtothepatient.Thescientificrationalfor
performingthenursingactivityshouldalsobeexplainedtothepersonorfamily.Nursinginterventions
withtheelderlyorfamilyinclude:

1. Givingsicknesscareincludingintensivecareordailycaresuchasfeeding,bathing,rangeof
motion,turning.
2. Enablingtheseniortoperformhisorherownhygieneandgrooming.
3. Implementingmedicalproceduresandtreatmentsasorderedbythephysician.
4. Encouragingtheseniortouseenergysavingdevices.
5. Adaptingproceduresortechniquestothehomesituation.
6. Encouragingaregimenofactivityorrehabilitationtoreducedisengagement.
7. Maintainingcommunicationwiththesenior,forexample,bylisteningtohimreminisce.
8. Reducesensoryandemotionalimmobility,i.e.,visitingwithanelderlycoupleorbringthema
bouquetofflowers.
9. Meetingspiritualneedsbycallingtheminister,readpassagefromtheBible,sayaprayerattheir
request.
10. Maintainingcommunicationwiththefamilyorsignificantothers.
11. Teachingandcounselingthepersonorfamilytohelpthembecomemoreadaptiveor
independent.
12. Reducinganxietybybeingsupportiveandavailabletothepersonandfamilyexperiencingdeath.
13. Referringtheelderlypersonorfamilytohealth,socialandwelfareagenciesasindicated.

Thelistcouldgoonandon.Throughnursinginterventions,youhelpthepersonorfamilymeetthe
needsthatcannotbemetbytheself.

Tosummarize,nursinginterventionsinclude:

1. Helpingtheperson/familycopewithactualorpotentialstressor.
2. Eliminatingasourceofstress.
3. Helpingtheseniordevelopnewbehavior,strengthenanexistingoneormodifyordiminisha
presentbehavior.
4. Supportingtheseniorinhisorherpresentbehavior.
5. Preventingfurtherinjuryorcomplications.
6. Manipulatingtheenvironmenttopromoteadaption(Bower1972).

Theelderlypersonmayhavemanyneedstobemetphysical,social,emotionandspiritual.Oftenthe
followingbasicneedsareoverlooked.However,theycanbemetwithlittleextraeffortonthepartof
thenurse.Rememberthattheelderlypersondesiresto:

17

 1. Berecognizedasapersonandnotregardedasaroomnumber,adisease,aproblem,
grandma,orlessofapersonbecauseofage.
2. Belistenedto
3. Becomforted,tohavedistressrecognized,perceivethathealthcareworkersaremakingefforts
tomakehimorherphysicallyandemotionallycomfortable;
Theagedpersoncantoleratepainifheorsheisnotbeingneglected.
4. Beremembered:Thepersonfearsbeingoverlookedandforgotten.
5. Learnwhatiscausinghealthproblemsordistressinterminologythatheorshecanunderstand.
6. Knowwhattreatmentandcareisplanned,lengthoftreatmentandwhatcanbeexpectedasan
endresult.
7. Receivequalitycare.
8. Havesomeselfdeterminationaboutwhatactivitiesheorshewilltakepartinsolongasheor
shedoesnotinjureselforothers.

Familymembersofthepatientoftenhavebasicneedsthatareoverlooked.Thefamilymembersmay
alsobeaged.However,theydeservethesameconsiderationasthepatient.Theyshouldnotbetreated
asinfantsorasincompetents.Familymembersalsoneedtobecomfortedemotionally,andsometimes
physically,whentheyfeelguiltyorworried.

Thefamilyneedstobeinformedasfullyaspossibleaboutthesituationandexpectedresultsofthe
treatmentandcare.Familymembersalsoneedencouragementandsupportastheyencounterthe
stressofillnessinthelovedoneandworktorestoreandmaintainwellbeingandpreventfurther
complicationsinthepatient.

InterventionincludestheINDEPENDENTFUNCTIONSof:

a. Doingallhygieneandcomfortmeasures.
b. Planningandcreatinganenvironmentconducivetowholenessandsafetyfrominjuryandrisk.
c. Teachingandcounseling,eitherformallyorinformally.
d. Offeringofselftoimpartstrengthandcouragetoanotherasheorshecopeswithproblems.
e. Socializinginapurposefulmanner.
f. Makingareferraltoanotheragencywhenindicated.

InterventionincludestheDEPENDENTFUNCTIONSof:

a. Doingalltheministrationsorproceduresthatimplementthemedicalregimenoutlinedbythe
physician.
b. Doingalltheministrationsorproceduresthatimplementtheregimenbyotherhealthcareteam
members.

Interventionalsoincludes:

a. Coordinatingcaregivenbyotherhealthteammembers.
b. Collaboratingwithotherstoprovidecontinuityofcare.

18

 c. Directingothers,includingthefamily,togivecaretotheelderlyperson.

Bowerclassifiesinterventionintothreenursingactions:

A. Supportive
B. Generative
C. Protective

Supportivenursingactionsprovidecomfort,treatmentandrestoration.Thesemeasuresaugmentthe
personspresentadaptivecapacity,helphimorhercopemoreeffectivelywithstressandprevent
furtherhealthproblems.Inaddition,supportiveinterventionsmaximizethepersonsorfamilys
strengthsandprovideguidance,encouragementorrelieftoenablethepersontoregainhealth.

Generativenursingactionsareinnovativeandrehabilitative.Theyhelpthepersonorfamilydevelop
differentapproachestocopingwithstressorcrisisandareespeciallyusedwhenassistinganotherwith
strugglesinvolvedinrollchangesoridentitycrisis.

Protectivenursingactionsaremeasuresthatpromotehealthandpreventdisease.Theyimproveor
correctsituations.Examplesareimmunizations,healthteachingoranticipatoryguidance;orpreventing
complicationsanddiseasesequelae(Bower1972).

EVALUATION
Evaluationisthepurposefulexaminationanduseofmeasurementdata,devicesandmethodsto
determineeffectivenessofnursingactionsandyourapproachtowardachievingshortrangeandlong
rangepatientcaregoals.

Evaluationalsoincludesdeterminationoftheproblemsthathavebeenresolved,thatarestill
unresolvedandnewonesthathavearisen.Evaluationisthelaststepinthenursingprocess.However,
evaluationcannotbeseparatedfromassessment,formulatinganursingdiagnosis,determining
objectivesandplanningcareandintervention.

Evaluationincludespredictingoutcomesthroughlongtermandshorttermgoals.Theseoutcomesare
expressedasbehavioralobjectives(patientresponses)thatyouexpecttoseeafternursingintervention.
Theyindicateprogressinachievementofstatedgoals.Thecurrentbehaviorsofthepatientactasa
baselineforexpectedchangewithinacertainlimit.

Statementsofgoalshelpyounotonlytodeterminespecificinterventionstouse,butalsothespecific
patientbehaviorsthatwouldindicatethatthesegoalshavebeenachieved.Whenabehavioral
objective(predictedoutcome)isreached,anewobjectivecorrespondingtoprogressinstatusiswritten
(Murray1980).

19

Behavioralobjectivesarebasedonprioritiesofcare.Theyestablishthecriteriaforevaluation.They
mustbeeitherobservabletotheclientortothenurse.Iftheyarenotobservable,theymustbe
measurableinsomeway.Therefore,thecauseofunexpectedoutcomescanbedeterminedandfurther
negativeeffectscanbeavoided.

Nursingcanbeevaluatedfor:

EFFORT,EFFECT,EFFICIENCY(Curtis1975)

MeasuringEFFORTinvolvesaskingthefollowingquestions:

1. Whathasbeendonecomparedtothestatedobjectiveofcare?
2. Wasasmuchdoneascouldhavebeendone?

MeasuringEFFECTinvolvesseekinginformationaboutchangeorlackofchangeinthepatients
situation:

1. Wasthechangeimportant?4.Wasthechangesafe?
2. Wasthechangeintended?5.Wasthechangenecessary?
3. Wasthechangeexpected?6.Wasthechangedesirabletothepatientandthenurse?

MeasuringEFFICIENCYinvolvesseekinginformationon:

1. Howactionswereperformedintermsoftime,energyandmaterials?
2. Iftheresultsofnursingcareweresatisfactory,howmanyactionswerenecessarytoaccomplish
thecare?

Evaluationsshouldbecontinuoussothatinsightsgainedcanbeusedtoreassesstheperson,modify
plansandimprovecarethroughoutthenursingprocess.Evaluationbenefitstheseniorandthenurse
becauseitprovidesafinalstatementaboutpatientprogressandisacriticalexaminationofnursing
practice(Murray1979).

Evaluationofcareisdirectlyrelatedtoaccountability.Accountabilityisthestateofbeingresponsible
foryouractionsandbeingabletoexplain,defineormeasuretheresultsofyourdecisionmaking.
Accountabilityinvolvesmeasuringyoureffectivenessagainstasetofcriteria.Thesecriteriamightbe
theunitsgeneralcarestandards,theagencyspoliciesorthepatientscareobjectives.Accountability
involvesvalidatingintangiblessuchasattitudesandsubtlenuancesaswellasovertcaremeasures.You
areaccountabletotheclient,thefamily,thegroup,theagency,thephysician,otherhealthcareteam
membersandthecommunity.Youraccountabilityassuresoptimumhealthcaredelivery.

Insummary,yourresponsibilityisto:

1. Assessthoroughlytheseniorshealthcareneeds.Thiscannotbedelegated.Toolscanbe
utilized,butitisyourresponsibilitytovalidateanyinformationonanursinghistoryform
collectedbysomeoneotherthanyourself.
2. Determinenursingdiagnosisbasedonyourassessment.

20

 3. Planwiththeteam,superviseothersandteachcaremeasuresneededbythepersonorfamily.
Youmustassumeresponsibilityforthepatientcareobjectivesandthelevelofcarerendered.
Therefore,yourresponsibilitywillincludesupervising,teachingandassigningpersonnel
accordingtotheirqualificationsandtheseniorsneeds.
4. Givecarewhenindicated,actingasarolemodelforotherstaffmembers.
5. Evaluatecareanddeterminewhetherornotgoalshavebeenmet.Youmusttakecorrective
actionasindicated.

Throughthisprocessyoudemonstrateaccountability.

Asyoureadthestepsofthenursingprocess,youarenodoubtawarethattheprocessiscontinuous
andcircular.Somestepsoftheprocessoverlap.Forexample,whileyouaredoingoneintervention,
suchasbathingthesenior,youaresimultaneouslyassessinghimorherandmentallymakingaplan.
Thatplanmightbehowyouwillcontinuewithyourinterventionofgivingskincareandambulation.
Youmaythinkthatyourmentalorverbalplanissufficient.However,youwilllikelyfindthata
writtenplanisessentialtoprovideforconsistencyofcare.Othernursingteammemberscannot
readyourmind.Sharewhatyouknowandplan,boththeteamandthepatientwillbenefit.

THEGERIATRICASSESSMENT

BASICCONSIDERATIONS

Approachinganelderlypatientforahealthhistoryandconductingtheinterviewneednotbe
difficultifyouanticipatehis/herspecialneeds.Ifpossible,plantotalkwiththeelderlyclientearlyin
thedaywhenhe/sheislikelytobemostalert.Manyelderlyexperiencethesocalledsundown
syndrome.Thismeanstheircapacityforclearthinkingdiminishesbylateafternoonorearly
evening.Someofthesepatientsmayevenbecomedisorientedorconfusedlateintheday.

Haveacomfortablechairavailableforyourelderlypatient,(ifnotonbedrest)especiallyifthe
interviewwillbelengthy.Ifthepatientisonbedrest,thenhaveacomfortablechairforyourself.
Besuretoencourageyourpatienttomovearoundinbedorchangepositionoftenbecausesome
orthopedicdisabilitiesmaymakebeinginonepositionforalongtimeuncomfortable.

Theelderlymayhavemildhearingandvisionloss.Sitcloseandfacehim/her.Speakslowlyinalow
pitchedvoice.Donotshoutatthepatientwhohasahearingproblem.Shoutingraisesthepitchof
yourvoiceandmaymakeunderstandingmoredifficult,noteasier.Hearinglossfromagingaffects
perceptionofhighpitchedtonesfirst.

Trytoevaluateyourpatientsabilitytocommunicate,andhisreliabilityasahistorian,earlyinthe
interview.Ifyouhavedoubtsaboutthesemattersbeforetheinterviewbegins,askifafamily
memberorclosefriendcanbepresenttoverifyfacts.

21

 Donotbesurprisedifyourelderlypatientrequeststhatsomeoneaccompanyhim/herduringthe
interview.Thepatientmayhaveconcernsaboutgettingthroughtheinterviewalone.Having
anotherfamiliarpersonpresentduringtheinterviewgivesthenurseanopportunitytoobservethe
patientsinteractionwiththispersonandprovidesmoredataforthehistory.However,thismight
alsopreventthepatientfromspeakingfreelyaboutcertainsubjects.Therefore,plantohavesome
privatetimewiththepatientaswellastimewiththeotherpersonpresent.

GERAITRICASSESSMENTTOOL

ASOCIOCULTURALASSESSMENT

(Foruseonadmissiontothehospital,nursinghomeorresidenceforseniorcitizens.)

I. Identifyingdata
Name:Sex:
Age:Race/Ethnicity:
Dateofadmission/orfirstcontact:Referralsource:
Previousoccupationorpresentemployer:
II. Environment
a. Describeneighborhoodandgeographicalareainwhichyoureside:
Whataboutitwasimportanttoyou?
b. Describeyourcurrentorprevioushomeandarrangementofspace:
Whathealthhazardsareorwerepresent?
c. Whattransportationfacilitiesdoordidyouuse?
d. Whatleisureactivitiesorrecreationdoyoupursue?
Where?Withwhom?
e. Whatwasoristheenvironmentatwork?
Whathealthhazardswereorarepresent?
III. SocioeconomicLevelandLifeStyle
a. Howwouldyoudescribeyoursocioeconomiclevelandlifestyle?
Howdoyouthinkthesehaveaffectedyourhealth?
b. Howhasyourhealthstatusaffectedyourlifestyle?
c. Whatchangesdoyouexpectinyourlifestyleasaresultofgrowingolder?
Illness,hospitalization,admissiontohospital?
d. Whatspecialpracticesorfoodsdoyouconsideressential?
IV. FAMILYPATTERNS
a. Maritalstatus.
b. Children.
c. Otherimportantmembersofthefamily.
d. Whoresidesinthehomewithyou?
e. Whatistheusualdailylivingpatterninyourfamily?
f. Whatfamilyeventsareimportant?
g. Whatritualsareimportantinyourfamily?

22

 h. Howdodailylivingpatternandritualsaffectyourhealth?

FamilyFunctionsandInteractions:

Whatisyourroleinthefamily?

Howaredecisionsmadeinthefamily?

Whohelpsprovideforthefamily?

Whohastheresponsibilityforthevariousfamilytasks?

Whatareyourspecialconcernsinyourfamily?

V. RELIGIOUSPRACTICES
a. Whatchurchorreligiousdenominationdoyoubelongtoasamember?
b. Areyouactiveinthatchurch?
c. Aretherespecialbeliefsthatyouadhereto?
Howdothesebeliefsaffectyourhealth?
d. HowdoyouseeyourrelationshiptoGodduringthistimeperiod?
WhataffectdoesGodhaveonyourhealthorillness?
e. Ifyoudonotprescribetoaparticularreligion,whatareyourbasicbeliefsandvalues?
f. Howdothesebeliefsandvaluesaffectyourhealthorillness?
g. Whatcanthenursedotoassistyouinpracticingyourreligionorbeliefsduringyourstay
atthiscenter?
VI. MEMBERSHIPS
a. Whatgroups/organizationsinthecommunitytoyoubelongto?
b. Whatisyourroleinthesegroups?
c. Howmuchsatisfactiondoyougetfromgroupactivities?
VII. PERSONALVALUES(considerexpressedidealvs.real)
a. Whatareyourideasaboutthefollowing:
1. Manandtheenvironmentrelationship?
2. Privacyvs.groupinteraction(beingwithothers)?
3. Possessions(personalvs.shared)?
b. Timeorientation:
1. Doyouliketohavethingsdonepromptly?
2. Doyourelyonpastexperiencesprimarily?
3. Doyouliketoplanaheadintothefuture?
4. Howdoyoufeelifyouknowthatyouorsomeoneelseisgoingtobelatetoan
event?
c. WorkorActivityLeisureOrientation:
1. Howmuchtimedoyouspendinworktasksdaily?
2. Doyouprefertobebusy?Sittingandthinking;Readingorrelaxing?
3. Whatdoyoudotorelax?

23

 4. Howmuchtimedoyouspendinleisuredaily?
d. Attitudetowardchange:
1. Howdoyoufeelwhenyouhearthewordchange?
2. Howoftendoyoumake/haveyoumadechangesinyourlife?
3. Whatchangeswouldyouliketomakeinyourself?Inothers?Intheenvironment?
e. Education:
1. Levelofschoolachievement?
2. Howimportantiseducationtoyou?
3. Whatdoyouconsidernecessaryforachievement?
f. HealthIllnessValueorDefinitions:
1. Whendoyouconsideryourselformembersofyourfamilyhealthy?
2. Whendoyouconsiderthemill?
3. Whatdoyoudowhenyouormembersofyourfamilybecomeill?
4. Whatcustoms,specialpracticesorritualsdoyouandyourfamilyengageintokeep
healthy?
5. Doyouandyourfamilyhaveanyspecificbeliefsorobserveanyspecifictraditions
concerninghealth?

NOTE:Thistoolcouldbeadaptedbythenursewhoisworkinginthehomehealthcareagencyandin
othersettings.

PHYSICALASSESSMENT

(Foruseonadmissiontothehospital,nursinghomeorresidenceforseniorcitizens.)

TheHealthhistoryIncludestheFollowingData:

I. IdentifyingData:
Name:Sex:
Address:Race/Ethnicity:
Age:
MaritalStatus:Ifwidowed,when?
Occupation:Ifretired,date?
Reasonforcontactinghealthagency:
II. AconcisestatementoftheChiefComplaintanditsDuration
III. Concisechronologicaldescription:Presenthealthstatusandpresentillness
IV. PastMedicalHistory
(Beginningasfarbackasthepersoncanrememberandcontinuinguptothetimewhenhe
consideredhimselftobeingoodhealth.)
a. Childhood:
b. Medical:
c. Surgical,includingaccidents:
d. Psychiatric:

24

 e. Obstetrical:
Number/outcomesofpregnancies,abnormalitiesorcomplications.
f. Hospitalizations:
Includenamesofhospitals,dates,attendingphysiciansandproblems.
g. Previousroutineorperiodicexaminations.
h. Exposuretoknowncauseofillness:
Travelinforeigncountries,exposuretotoxicsubstances.
i. Allergiestowhatandwhatreactions:
V. PersonalandSocialHistory
a. Childhood:
Birth(when&where),familygroup,education,environment,problems:
b. Adulthoodemploymenthistory,militaryservice:
c. Sexual&maritalhistorymaritalstatus,sexualactivity,children:
d. Presentlifestyle:
Descriptionsofhome,occupation,familylife,affiliations,habits:
Tobacco:Typecigarettes,cigars,pipe,chewing,snuff.
Ageatwhichbeganuse.
Currentlevelofusage.
Beverages:Coffee,tea,cola.
Alcohol:Averagedailyuseorweeklyconsumption.
Drugs:Druguseincludinglegalandillegaldrugs,prescriptiondrugs,
overthecounterdrugs.
PresentscheduleanddosageSleepingpills,aspirin,weightcontroldrugs,
antihistamines,folkremedies,laxatives,
enemas,vitamins.
PersonalHabits:Sleep,workinghours,travel,vacation,hobbyorleisureactivities
e. Nutritionandhydration(sampleonedaysdietandfluidintake).
Specialdietneeds.
f. Familyhistory:
g. Healthstatusofcloserelatives:
h. Presenceofspecificdiseases:Diabetes,tuberculosis,cancer,mentalillness,illness
similartothepatientspresentillness:
i. Familytree:Includegrandparents,parents,siblings,children
j. Religiouspractices:Denomination,churchlocation,pastor,usualattendance.
k. Doyouanticipateanyspecificspiritual/religiousneeds?Ifso,what?

25

 THEREVIEWOFSYSTEMSANDTHEPHYSICALEXAMINATION

INCLUDESTHEFOLLOWINGDATA:

I. MEASUREMENTOFVITALSIGNS
Weight:Height:Pulse:(rate,rhythm)
Temp:Resp:(rate,rhythm)BP:(arm&position)

II. GENERALAPPEARANCE
Openingstatementdescribingmusculardevelopment,posture,positionofbody,body
movements,nutritionalstatus,appearanceofacuteorchronicillness,whetherhe/she
appearshis/herage,personalhygiene.)
a. HISTORYOFANYWEAKNESS:
Fatigue,malaise,fever,chills,weightgainorweightloss.
b. SKIN:
Color,temperature,turgor,moisture,pigmentchanges,bruises,pressureareas,
decubitus,lesions,rashesandscars(location),dryness,texture,appearanceofnails,size
andshapeoffingers(clubbing),useofhairdyesorotheragents.
c. HEAD:
Historyofheadache,headinjury,dizziness,syncope.
d. EXAM:
1. Skulldeformities
2. Scalpscaling
3. Haircolor,baldness,parasites
4. Faceexpression,edema,muscletics,paralysis
e. EYES:
Historyofpain,useofglasses,lastchangeinrefraction,diplopia,infection,glaucoma,
cataract.
1. Visionnear,distantandperipheral
2. Pupilsreactiontolightandaccommodation,equalityofsize
3. Conditionoflids,conjunctivaandscleramovements,theexpression,presenceof
discharge
f. EARS:
Historyofearaches,hearingloss,useofhearingaid,presenceoftinnitus,vertigo,
discharge,infection,pain.
1. Externalauditorymeatus,tympanicmembrane,generalappearance
2. Hearingdistancewhisperedwordheard
g. NOSE:
Historyofsinuspain,epistaxis,obstruction,discharge,postnasaldrip,colds,sneezing.
1. Externalsize,shape,smell,difficultyinbreathing,discharge
2. Internalpatency,polyps,septaldeviation,others.
h. MOUTH:

26

 Historyoftoothache,recentextractions,sorenessorbleedingoflips,gums,mouth,
tongueorthroat,disturbanceoftaste,thirst,hoarseness,tonsillectomy.
1. Lipspallor,cyanosis,lesions,dryness
2. Teethnatural,stateofrepair,dentures.
3. Gumsbleeding,retracted,color,hypertrophic.
4. Tonguecolor,size,deviation,hydration,lesions,tremors,paralysis.
5. Pharynxmotionofpalate,uvula,tonsils,gagreflex,posteriorpharynxhoarseness,
difficultyspeakingorswallowing,ulcerations,inflammation.
i. NECK:
Historyofpain,limitationofmotion,thyroidenlargement.
1. Generalstiffness,R.O.M.,tenderness,veins,pulses,bruits.
2. Thyroidenlargement,nodules,tenderness.
3. Lymphglandssize,consistency,tenderness.
j. THORAX:
Historyofpain,breastlumps,dischargeoroperations.
1. Chestsize,shapeandmovements.
2. Breastsnippledischarge,areola,contour,symmetry,masses(size,location,shape,
consistency,fixation),skinulceration,axillarynodes.
k. HEART:
Historyofpainordistress,palpitations,dyspnea(relatetoeffort),orthophea,
paroxysmalnocturnaldyspnea,edema,nocturia,cyanosis,heartmurmur,rheumatic
fever,hypertension,coronaryarterydisease,anemia,lastEKG.
1. Inspection:
a. Apexbeat,relationtomidclavicularormidsternalline.
b. Otherpulsations.
2. Palpation:
a. Size,vigorofapexbeat.
b. Leftsternalift,epigastricpalpation,thrills.
3. Percussion:
a. Distanceofdullnessfrommidsternallineinleftsecondtosixthorseventh
interspace.
4. Auscultation:
a. QualityandintensityofS1andS2ineachvalvearea.
b. Splitting.
c. ExtrasoundsS3andS4.
d. Murmurlocation,radiation,systolicordiastolic,intensity,frequency,
charactercrescendo,decrescendo,holosystolic.
l. LUNGS:
Historyofpain,cough,sputum(character,amount),hemoptysis,wheezing,asthma,
shortnessofbreath,bronchitis,pneumonia,TB,orcontactwith,dateoflastxrayorskin
testandtheresultsofthese.
1. Inspection:

27

 a. Breathingpattern.
b. Symmetry.
c. Venouspattern.

2. Palpation:
a. Vocalfremitus.
b. Useofaccessorymuscles.
3. Percussion:
a. Locationbyinterspacedullness,flatness,hyperresonance,ortympany.
4. Auscultation:
a. Typeofbreathsoundsvesicular,bronchial,orbronchovesicular.
b. Adventitioussoundsrales,cavernousbreathing,asthmaticbreathing,friction
rub.
c. Vocalresonancebronchophony.
m. ABDOMEN:
Historyofappetite,foodintolerance,dysphagia,heartburn,painordistressaftereating,
colic,jaundice,belching,nausea,vomiting,hematemesis,flatulence,characterandcolor
ofstools,anychangeinbowelhabits,rectalconditions,ulcer,gallbladderdisease,
colitis,hepatitis,appendicitis,parasites,hernia.
1. Inspection:
a. Distention.
b. Masses.
c. Peristalsis(visible).
2. Palpation:
a. Tendernessoflightordeeppalpation.
b. Masses(location,consistency,mobility,nodularity).
c. Rigidity.
d. Organoutlines(liver,spleen).
3. Percussion:
a. Abdominaldistension(airorascites).
b. Bladderdistension.
4. Auscultation:
a. Bowelsounds.
b. Bruits.
n. EXTREMITIESANDBACK:
Historyofintermittentclaudication,varicoseveins,thrombophlebitis,jointpain,
stiffness,swelling,arthritis,gout,bursitis,flatfeet,infection,fracture,musclepain,
cramps;assistancedevicesutilized(prostheses,cane,crutches,walker,wheelchair).
1. Bloodvesselspulseveins.
2. Jointstenderness,deformities,crepitation,rangeofmotion.
3. Edemalocation,pitting,discoloration.
4. Reflexes.

28

 5.Sensationpainandtemperature,vibrationposition.
6.Muscularfunctionstandingontoes,strengthofmovement.
7.Gaitandstancewalking,standingwitheyesclosed.
8.Backpain(locationandradiation,especiallytoextremities),stiffness,limitationof
movement.
o. GENITOURINARY:
Historyofurinarytractrenalcolic,frequency,nocturia,polyuria,oliguria,hesitancy,
urgency,dysuria,narrowingofstream,dribbling,incontinence,hematuria,albuminuria,
pyuria,kidneydisease,facialedema,renalstone,cystoscopy;genital(male)testicular
pain,scrotalchange,nodulesinscrotum;genital(female)menstrualhistory,vaginal
bleedingordischarge,menopauseandassociatedsymptoms,dateoflastPAPsmear,
venerealdiseasegonorrheaorsyphilis(notedate,treatment,complications);sexual
drive,activity,pleasure,discomfort,impotence.
1. ExaminationofthemalegenitoUrinarySystem:
a. Penis
b. Scrotumsize,symmetry,consistency,tenderness,masses,atrophy.
c. Inguinalregionpulses,lymphglands,hernia,parasites.
d. Characterofurinepresenceofindwellingcatheter,datechanged.
2. Examinationofthefemalereproductivesystem:
a. Externalgenitalia.
1. Vulvaulceration.
2. Urethradischarge
3. Pelvicrelaxationcystocele,rectocele,prolapseuterus(degree).
b. Internalgenitalia.
1. Speculumexamofvagina(discharge,ulcerations,irregularities).
2. Cervix(ulceration,irregularity),PAPsmear.
a. Examinationoftherectum:
a.Externalinspectionhemorrhoids,perianalskin,pilonidalcyst.
b.Internalpalpationsphinctertonicity,abscess,prostateenlargement,rectal
masses,impaction.

p.CENTRALNERVOUSSYSTEM:

1.Generalhistorysyncope,lossofconsciousness,convulsions,meningitis,

encephalitis,stroke.

2.Mentativeaphasia(describe),emotionalstatus,mood,orientation,memory,

changeinsleeppattern,psychiatricillness.

3.Motortremor,weakness,paralysis(describeinvolvement),clumsinessof

movement.

29

 4.Sensoryneurologicalpain,reducedsensation,paresthesia.

q.HEMATOPOIETIC:

Bleedingtendencies;ofskinormucousmembranes;anemiaandtreatments,bloodtype,

transfusions,anyreactions;blooddyscrasias,exposuretotoxicagentsorradiation.

r.ENDOCRINE:

Historyofnutritionandgrowth;thyroidfunction(changesinskin,relationshipof

appetitetoweight,nervousness,tremors,thyroidmedications),diabetesorits

symptoms,hirsutism,secondarysexcharacteristics,hormonetherapy.

ActivitiesofDailyLivingSurvey

Needsassistance,

describetypeof

IndependentassistanceneededDependent

BathingyesAnyCommentsyes

DressingyesAnyCommentsyes

Toileting*yesAnyCommentsyes

FeedingyesAnyCommentsyes

TransferringyesAnyCommentsyes

AmbulatingyesAnyCommentsyes

TurninginBedyesAnyCommentsyes

*Describewhetherpersoncanasktobetakentobathroomoristotallyincontinent.

Note:Thistoocanbeadaptedtothehomehealthsettingandothernursingcaresettings.

30

 CHAPTER II

PSYCHOLOGICAL
ASSESSMENT

31

 PSYCHOLOGICALASSESSMENT

(Foruseonadmissiontothehospital,nursinghomeorresidenceforseniorcitizens)

I. IdentifyingData:
Name: Sex:
Age: Race/Ethnicity:
MaritalStatus: Children:
WhereEmployed: Occupation(past,present):
Everactiveinadifferentoccupation?
Ifyes,whydidyouchangeoccupations?When?
Othermembersinhousehold:
Dateofadmission/firstcontact?Referralsource?
II. HealthHistory:
a.Haveyouhadpreviousadmissionstothehospital?
Toanothernursinghomeorresidence?
b.Describesignificantaspectsofyourhealthhistory.
c.Whatdoesitmeantoyoutobeinthehospitalornursinghome?
d.Whatisyourusualsourceofhealthcare?
e.Howaccessiblearehealthservices?
Istransportationreadilyavailable?
Doyouhavesomeformofhealthinsurance?
f.Whatmedicationsdoyoucurrentlyuse?
g.Describeanydrugallergies.
h.Whatdoyouconsideryourmajorpresentproblemorareaofconcern?
i.Whendidtheproblembegin?
J.Wastheonsetsuddenorgradual?
k.Whatdoesthisproblemorillnessmeantoyou?
l.Whatdoyouconsiderthestressfuleventtriggeringyourproblem?
m.Haveyoueverexperiencedasimilarproblem?
Ifyouhave,whatwastheproblem?
Howdidyouhandletheproblem?
Wereyourcopingpatternssuccessful?
III. LifeStylePatterns:
a. Whatisyourusualpatternofliving?
AreyouabletocareforyourownADLs?(ActivitiesofDailyLiving.)
Whattimeofthedaydoyoufeelthemostalert?
b.Whatisyourpresentlivingsituationandenvironment?
Arethereanyhazardstohealthordevelopment?
c.Howdopresentcircumstancesdifferfromusualpatternofliving?
d.Havethingschangedwithyouragingorillnessordisability?
Ifso,how?

32

IV. PerceptualAbility:
a.Describeyoursensoryabilityoranyimpairmentrelatedto:
SightTaste
HearingSmell
TouchBalance
Painorunusualbodyperceptions
b.Dobrightlightsorloudnoisesbotheryou?
c.Ifyouaremoresensitivetolightornoisenow,isitrelatedtoyourillnessortoconditionsexisting
inthehospitalorresidence?
d.Doyouhavespecialvisions?
Ifso,describethemandwhenandwheretheyoccur.
e.Doyouhearvoices?
Ifso,whatdotheysayandareyouabletoconversewiththem?
f.Whatareyourfoodpreferences?
Whatfoodsarenottastefulorenjoyabletoyou?
g.Whatkindsoffeelingsdoyouhaveinvariousbodyparts?
Areyouespeciallyawareofanybodypartorfunction?
h.Whatsituationsrequireassistancetomaintainbalance/mobility?
Whatkindofassistancedoyouneed?

V.EmotionalStatus:
a.Selfconcept:
Howwouldyoudescribeyourself?
Howdoyoufeelyouhandleyourselfandyourlife?
Whatwouldyoudescribeasyourattitudetowardlife?
Whatarethemostimportantvaluestoyou?
Whatdoyoulikebestaboutyourself?
Ifitwerepossible,whatistheprimaryaspectofyourselfthatyouwouldliketochange?
Doyoupreferdoingthingsaloneorwithothers?
b.Egoideal:
Whatgoalsoraspirationsdoyoupresentlyhave?
Doyoufeelyouhavemanagedtoachieveyourgoalsinlife?
c.Superego:
Whichofthefollowingcomesfirstforyou?
1.Pleasure
2.Yourgoals
3.Essentialtasks
d.Howdoyourespondtosituationsthatrequireyoutodosomethingyouarereluctanttodo?
1.Doyouignorethetask?
2.Doyouplungeinandcompleteitassoonaspossible?
3.Doyoudelaythetaskaslongaspossible?
e.Whatrulesorcustomsaredifficultforyoutofollow?

33

f.Whatdoyouconsiderthemostimportantteachingsthatweregiventoyoubyyourparentsor
family?
Thatyouhavelivedby?
Whatcausesyoutofeelguilty?
g.Relationstoothers:
Doyoushareyourfeelingswithanotherwitheaseorwithdifficulty?
Withwhomdoyoushareyourfeelings?
Whocanyoutrusttohelpyouintimeofneed?
Whoorwhatdoyoucareaboutthemostinyourlife?
Whodoyouthinkcaresmostaboutyou?
Howdoyouseeyourlifefittingintothelivesofothers?
Howdependentorindependentoffamilyorfriendsareyou?
h.Senseofautonomy:
Whatdoesthetermfatemeantoyou?
Whatdoyoufeelhascontroloverwhatishappeningtoyou?
Howmuchcontroldoyouexertoverothers?
i.Howhasagingorillnessorhospitalizationoradmissiontonursinghomeorresidenceaffected
yourfeelingsofcontrolorlackofcontrol?
j.Reactionandcopingwithsituations:
Whatsituationsorpersonscauseyoutofeelcalm,secureandhappy?
Whatsituationsorpersonscauseyoutofeelupset,embarrassed,anxiousoranger?
Whatusuallyresultsfromyourbehavior?
k.Adaptivepattern:
Whatisyourusualpatternofrelatingtothoseclosetoyou?
Toagroupsituation?
Howmuchdoesanothersreactionorbehaviorinfluencehowyouwillact?
Howimportantisanotherpersonsbehaviororfeelingstoyou?
Whatisyourreactiontofrustration?Tosuccess?
Whichofthefollowingareyoulikelytodo?
Goalongwiththepersonorsituationtokeeppeace?
Blameothersifsomethinggoeswrongforyou?
Consideryourselfthecauseifsomethinggoeswrong?
Feelmoreangrythaniswarrantedbythesituation?
Letothersknowabruptlyofyourfeelings?
Saylittleaboutyourfeelings,hopingtheotherpersonwillguesshowyouarefeeling?
Feelreluctanttoactinanunfamiliarsituationwithoutpermissionorencouragement
fromsomeone?
Feelconfidentinunfamiliarsituationsandtakechargeofthingsifitisindicated?
Encourageotherstodotheirbestworkpossible?
Considerthatothersareunlikelytodothejobaswellasyourself?
Whatdoyoufindbestrelievesyourtensioneating,smoking,drinking,drubs,sleep,activity
etc?

34

VI.UseofLeisure:
a.Whatactivitiesdoyouenjoyforrecreationorrelaxation?
b.Howoftendoyouengageintheseactivities?
c.Howdotheseactivitiesaffectyourhealth?

VII.CommunicationPattern:(Observeandlistenfor)
a.Abilitytoexpressthoughtsandfeelings(talksfreelyorhesitancy,writes,draws,uses
nonverbalbehaviorprimarily).
b.Describesvocabulary(varietyofwordsused,repetitionofwords,slangorcorrectgrammar).
c.Enunciationofwords.
d.Rateofexpressionofspeech(howquicklyanswers,rapidityinflowofspeech,hesitations,
smoothvs.unevenrate,urgencyofspeech).
e.Abilitytoexpresshisideas(coherent,logical,confused,circumstantial,tangential,poverty
ofideation).
VIII.CognitiveStatus:(Observeandlistenfor)
a.Levelofconsciousness(alert,lethargic,confused,stuporousorcomatose).
b.Orientationtotime,place,person.
c.Educationlevel.
d.Abilitytorecallfarpast,immediatepastandpresentevents(whatbroughtyouintothe
hospitalorresidence?Tellmeabouttheeventsthatledyoutoyourhospitalizationor
admissiontonursinghomeorresidence.TellmeMAJORthingsaboutyourselfandyourpast
life).
e.Attentionspan(attendstoimmediatestimuli;lengthofconcentrationorattentionspan;is
notdistractedbyexternalstimuli;howcapableoffollowingtrainofthought,whatstimuli
distracts,howlonginterviewproceededbeforepersonshowedsignsoffatigue,preoccupied
withselforsomeevent).
f.Speedofresponsetoverbalstimuli(answersimmediately,quicklyorslowly,hesitates,
ignorescertainstatements).
g.Remainsinreveriestateorinprimaryprocess(daydreams,fantasizes,talksaboutmaterial
thatseemsnonsensicalorisdifficulttofollow).
h.Abilitytograspideastofollowdirections.
i.Abilitytodologicalthinkingorproblemsolving(orunabletodocauseeffectassociations,
statesloose,magicalornonsensicallogic).
j.Abilitytoabstract(answersquestionsliterally,isabletoelaborateorexplain,cangive
meaningsforbehaviorsituations).
k.Presenceofdelusionsordegreeofrealityinbeliefsystem.
l.Apparentinsightintoproblemorsituation:
Whathaveyoubeentoldaboutyourillness?
Whatdoyouthinkisthecauseofyourproblem?
Whydoyouthinkyouhavebeenadmittedtohospitalornursinghomeorresidence?
m.Awareofneedformoreknowledgeaboutillnesssituation:
Whatquestionsorconcernsdoyouhaveaboutyourillness,hospitalstay,admission

35

 tonursinghomeorresidence?
IX.EgoFunctions:
a.Interviewershouldnotethefollowingduringtheinterview:
Whatwastheprimaryemotion?Wasitappropriatetothesituation?
Duringtheinterview,whatnonverbalbehavioraccompaniedstatements?
Whatquestionselicitedbehavioralmanifestationsofdiscomfortoranxiety?
Wasthereaccentuateduseofanyonepatternofbehaviorduringtheinterview?
DidthepersonusetheyinsteadofIwhenrespondingtoquestions?
Washe/sheawareofbodypartsandfunctionswithoutexcessivepreoccupation
withhimorherself.
Wasthepersonrealisticordidhe/sheshowdisturbedrealitytwisting?
ForexampleIsthepersonadaptingtoreality?
Doeshe/sheshowpoorjudgment?
Doeshe/sheunderstandtheconsequencesofhis/herbehavior?
Doesrealityinterferewithcreativebehavior?
Presenceofdelusions?Hallucinations?
Hasthepersonlearnedthesociallyacceptablemethodofdealingwithdrivesand
feelings?
Whatdefensemechanismsareapparentlycommonlyused?
Whatdefensemechanismswereusedduringtheinterview?
Doesbehaviorappearovercontrolled,undercontrolledorwithoutcontrol?Describe.
Doesthepersonappearabletohavethevariousaspectsofhispersonalityintegrated?
Whataspectsofhisbehaviorappearfragmentedorlackinginunityorautonomy?

Summaryofimpressions
(Note:Anydiscrepanciesbetweenpatientsorclientsperceptionandthatofinterviewerorcaregiver.)

A.IntrapersonalFactors:
1.Physical(appearance;posture;faces;dress;hygiene;rangeofbodyfunctions;physical
findingsthatevidenceanxiety).
2.Psychological(cognitiveandperceptualabilities;thoughtprocess;emotionalstatus;ego
functions;adaptiveordefensivemechanismsused;feelingsaboutselfandbodyimage;
values;attitudes;needs;expectations;aspirations;behaviorpatterns;creativeexpressions;
needs;strengths;limits).
3.Developmental(degreeofapparentnormalcy;apparentstageofbehaviorandcopingor
defensivemechanisms;pastlearninghistory;perceptionofenvironmentandfamilyvalues;
goalsandideasandtheinfluenceofthese;howcurrentleveloffunctioningandlifestyle
relatetocultureorethnicity;age,andsexofperson).
4.Social(superegofunctions;behaviororsocializationpattern;useoflanguageand
communicationsskills;activitiesofdailyliving;perceptionofrelationstoothers;value
system;customs;taboosorsuperstitions;understandingofownrolesandrolesofothers).
5.Interpersonalfactors(familystructures;relationshipwithfamily,friendsandothers;

36

 communicationability;socializationlevel;expectationsoffamily,friends,caregiversand
othersinpresentsituation;abilitytoanticipateconsequencesofbehavior;resources).
6.Extrapersonalfactors(culturalfactors;socialclasslevel;occupation;workrelatedresources;
environmentalorworkrelatedstresses;residenceandgeographicallocation;financial
resources;relationshiptocommunity;communityresources;effectiveoftimeofday,
temperatureandweatheronbehavior;useofspaceandprivacy).
B.Recommendations:
Shorttermgoals:Longtermgoals:

*Thistoolcouldbeadaptedbythenursewhoisworkinginthehomehealthagency.

ATTITUDESTOWARDAGING

Communicatingwithanelderlypatientmaychallengeyoutoconfrontyourpersonalattitudesand
prejudicesaboutaging.Examinethesefeelingsbeforetakingthepatientshistory,anddecidein
advancehowyouwillhandlethem.Anyprejudicesyourevealwillprobablyinterferewithyourefforts
tocommunicate,sinceelderlypatientsareespeciallysensitivetoothersreactionsandcaneasilydetect
negativeattitudesandimpatience.

Thenconsideryourpatientsattitudetowardhisorherbodyandhealth.Anelderlypatientmayhavea
distortedperceptionofhisorherhealthproblems;maydwellonthemneedlesslyordismissthemas
normalsignsofaging.Apatientmayignoreaseriousproblembecauseheorshedoesntwantthese
fearsconfirmed.Ifyourpatientisseriouslyill,thesubjectsofdyinganddeathmayariseduringthe
healthhistoryinterview.Listencarefullytoanyremarksyourpatientmakesaboutdying.Besuretoask
abouthisreligiousaffiliationandspiritualneeds.Manyelderlypatientsfindcomfortintheirreligious
beliefsandpractices.Youshouldalsoinquiretactfullyaboutthematterofalivingwill(Health
AssessmentHandbook1992).

THENEEDFORPATIENCE

Patienceisthekeytocommunicatingwithanelderlypatient.Heorshemayrespondslowlytoyour
questions.Donotconfusepatiencewithpatronizingbehavior.Yourpatientwilleasilyperceivesuch
behaviorandmayinterpretitasalackofgenuineconcernforhimorher.Keepyourquestionsconcise,
rephrasethosehe/shedoesntunderstandandusenonverbaltechniquesinameaningfulway.

Tofurtherfosteryourelderlypatientscooperation,takealittleextratimetohelphimorherseethe
relevanceofyourquestions.Youmayneedtorepeatthisexplanationseveraltimesastheinterview
progresses.However,donotrepeatquestionsunnecessarily.Askonlyforinformationthatisrelevant
tothecondition.Forexample,youwouldnotobtainadetailedobstetrichistoryfroma75yearold
womanwhodoesnothaveagynecologicalproblem.

37

Onceyouhaveobtainedanelderlypatientscooperation,youmayhavesometroublegettinghimorher
tokeepthestorybrief.Heorshehasagreatdealofhistorytorelateandmayreminisceduringthe
interview.Trytofindtimeforthis.Letthepatienttalk.Youmayobtainvaluablecluesaboutthe
currentphysical,mentalandspiritualhealth.Ifyoumustkeepthehistorybrief,lethimorherknow
priortobeginningtheinterview.Lethimorherknowtheexacttimelimits.Offertocomebackat
anothertimeinordertochatwithhimorherinformally(HealthAssessmenthandbook1987).

THEELDERLYPATIENTSPASTHISTORY
Ageriatricpatientspastmedicalhistorycanbeextensive.Inorderforyoutocompletethehistory,itis
importantthatthepatienthaveadetailedrecallofallmajorillnesses,surgicalproceduresandminor
illnesses.Fracturesthepatientmayhaveexperiencedearlyinlife,forexample,mayfiguresignificantly
nowinosteoporosis.Asyourecordthepasthistory,trytofindouttheamountofstresshe/shehashad
recentlyandthewayhe/shehashandledprevioushealthproblems.Donotbeconcernedifhe/she
cannotrelatethismedicalhistorychronologically,justbesuretorecordhis/herageatthetimeeach
medicalconditionoccurred.

Payspecialattentiontoyourelderlypatientsmedicationhistory.Heorsheisprobablytakingsome
typeofmedicationroutinely.Findoutthenamesofallcurrentandpastmedicationswhetheroverthe
counterorprescriptiondrugs.Findoutthedosageandfrequencyofeachdrugandthepurposefor
takingthedrug.Asktoseeasampleofeachdrug,ifpossible,(HealthAssessmentHandbook1987).

THEELDERLYPATIENTSPHYCHOLOGICALHISTORY
Makeitapointtotalkwithyourelderlypatientabouthisfamilyandfriends.Askwithwhomhelives.
Askhowhespendshistime.Findoutwhatsignificantrelationshipsheenjoys.Ifyourpatientis
hospitalizedandseriouslyill,ormusttransfertoanothertypeifinstitution(suchasanursinghome),he
orshewillneedtheemotionalsupportoffamilyandfriends.Ifhe/sheisreturninghomeafteranillness,
he/shemayneedtheirassistance.

Ifyourpatientdoesnothaveafamilyoranyfriendsonwhomhe/shecandependforsupport,record
thisinthepsychologicalhistoryforpossiblelaterreferralofthepatienttoasocialworker.Recordthe
namesofthenextofkin.Withoutyourinterventionhere,lonelinessmaydiscouragetheelderlypatient
fromgettingwell.

Ifyourpatientisemployed,inquireabouthisorherjobinordertofindoutifthecurrenthealth
problemswillinterferewiththeirreturntowork.Talkwiththepatientconcerningplansforretirement.
Iftheyhaveanysuchplans,alsoexploretheirattitudestowardtheretirementphaseoflife.

Ifyourpatientexpressesfinancialconcerns,explorethemfurtherinafinancialhistory.Rememberto
askyourelderlypatientifheorshereceivesanypensionsorSocialSecuritypayments.

Whenappropriate,inquireaboutthepatientssexlife.Donotignoreitbecauseofapatientsage.
Approachthisaspectofthepsychosocialhistorywiththesamesensitivityandrespectforprivacythat

38

youwouldshowwithyoungerpatients.Ifthepatientisreluctanttodiscussthispartoftheirlife,donot
pressfortheinformation.

GERIATRICACTIVITIESOFDAILYLIVING

Yourgeriatricpatientsactivitiesofdailylivingmayaffecthis/herhealth.Inturn,his/herhealth
problemsmaythreatenhis/herindependence.Askhim/hertodescribeatypicaldayathome.Have
themincludeactivities,sleeppatternsandeatinghabits(TableI).His/hereatinghabitsmaysuggest
othersignificantlinesofquestioning.Findouthowmuchofanappetitehe/sheusuallyhas.Findout
howtheypreparefoodandhowmuchfluidisnormallyconsumed.Youcanputthisinformationintoa
chartshowingwhichfoodsthepatienteatsatwhichtimesduringtheday.

Askaboutmattersrelatedtothepatientsmobility.Ishe/sheabletomovearoundathomeeasilyand
safely?Canhe/shesupplythebasicneeds;food,clothingandshelter?Doeshe/shedrivetothe
supermarketordoesafrienddrivethem?Doeshe/sheusepublictransportation?Askifhe/sheexpects
tobeabletocontinuewithhis/hernormalroutineafterdischargefromthehospital.Ifnecessary,
consultwithasocialworkertodiscusswhatyouhavelearnedaboutthepatientsactivitiesofdailyliving
(HealthAssessmentHandbook1987)

Geriatriccareishinderedbydisabilitiesoftenassociatedwiththeelderlyclient.Theelderlypersonis
muchlesslikelytoreportlegitimatesymptomsofdiseaseinitsearlystages.Thisisaphenomenonthat
hasbeennotedbymanyauthorities.Forwhateverreasons,theelderlytendtowaituntilthedisease
hasprogresseduntilthesymptomsarereportedandtheyseekhelp.Evenincountriesthathave
completelyfreemedicalcare,underreportingisprevalentintheelderly.

Frequentlyfoundproblemsintheelderlyaredecompensatedheartfailure,correctablehearing
problems,correctablevisionproblems,activetuberculosis,severeanemia,chronicrespiratory
insufficiency,uncontrolleddiabetes,footdisease,dementia,depressionandothers.Thefollowing
reasonsarecommonreasonsthattheseconditionsareunderreported:(1)Thestigmaofreporting
diseaseasafurthersignofoldage.(2)Duetodepressionthepersonisnotinterestedinreturningto
optimalheath.(3)Theyareoftenafraidthattheywilllosetheirindependenceiftheyreportconditions.
(4)Intellectualloseinoldagecouldalsobeareasonfornotreporting.Ourhealthcaresystemrelieson
peoplereportingsymptomsandseekingtreatment.Whentheelderlydonotreportillnesses,itonly
compoundstheiroverallmedicalcondition.

TABLEIGERIATRICACTIVITIESOFDAILYLIVING

Whenquestioningelderlypatientsaboutdailyactivities,usegeneralquestionsthatwillelicithis/her
usualhabitsandwhetherhe/shehasproblemsperformingthem.Elderlypatientsmayalsohave
personalconcerns,financialortransportationproblemsthatkeephim/herfromhis/herdailyroutine.
Structureyourquestionsasoutlinedhere.

39

 DIETORELIMINATION
Whatdoyoueatonatypicalday?
Doyoufeelhungrybetweenmeals?
Doyouprepareyourownmeals?
Withwhomdoyoueat?
Whattypesoffooddoyouenjoymost?
Doyouhaveanyproblemseating?
Haveyounotedanychangesinyoursenseoftaste?
Doyousnack?Whenareyoursnacktimes?
Whatdoyouusuallyeatforasnack?
Whatareyourusualbowelhabits?
Haveyounoticedanyrecentchangesinyourbowelhabits?

EXERCISE/SLEEP
Doyoutakedailywalks?
Doyoudoyourownhousework?
Doyouhaveanydifficultymovingabout?
Hasyourdoctorrecentlyrestrictedyourexercise?
Hasyourdoctorrecommendedanyspecialexerciseprograms?
Whattimetoyougotobedatnight?
Whattimetoyouawaken?
Doyoufollowanyroutinesthathelpyousleep?
Doyousleepsoundlyorwakeoften?
Doyoutakeanapduringtheday?Ifso,howlong?

RECREATION
Doyoubelongtosocialgroupssuchasseniorsclubsorchurchgroups?
Whatdoyouenjoydoinginyourleisuretime?
Howmanyhoursadaytoyouwatchtelevision?
Doyoushareleisuretimewithyourfamily?

TOBACCO/ALCOHOL
Doyouusetobacco?Ifso,doyousmokecigarettes,cigars,pipe?
Howlonghaveyousmoked?Howmuchdoyousmokeeachday?
Ifyouquitsmoking,whendidyouquit?
Doyoudrinkalcohol?Howoftenandhowmuchdoyoudrink?
Doyoudrinkaloneorwithfriends?Hasdrinkingincreasedlately?

PERSONALCONCERNS
Doyouweardentures?Aretheyahindrancewhenyoueatortalk?
Doyouwearglasses?
Doyouhaveproblemswithyourvisionwhenyouwearyourglasses?

40

 Doyouhearthosearoundyouwithnodifficulty?
Doespoorhearinghinderanyofyouractivities?
Whatisyoursourceofincome?
Doyoushopforyourowngroceries?Ifnot,whodoesthisforyou?

41

CHAPTER III


PHYSICALASSESSMENT
AND
RECORDINGTHEFINDINGS

42

 GERIATRICREVIEWOFSYSTEMS

Thereviewofsystemsforanelderlypatientinvolveskeepinginmindthefollowingphysiologicchanges.
Theseareconsiderednormalintheagingprocess.Thesecommonpathologicdisordersaredescribedin
TableII(HealthAssessmentHandbook1992).

SKIN,HAIRANDNAILS

Skincolorandtexturecommonlychangeasapersonages.Yourpatientmayreportthathis/herskin
seemsthinnerandlooser,lesselastic,thanbefore.Thepatientalsoperspiresless.Thehairthins,grays
andbecomescoarser.Distributionofthehaironthescalp,faceandbodymayalsochange.Thepatient
maytellyouthattheirscalpfeelsdry.Thefingernailsmaythickenandchangecolorslightly.Askifthe
patientcantakecareofhisorherownnails.

EYESANDVISION

Yourpatientmayreportincreasedtearing.He/shemayalsoexhibitpresbyopia(diminishednearvision
duetonormaldecreaseinlenselasticity).Askifhe/shehasexperiencedanychangesinhisvision,
especiallynightvision.Doeshe/sheneedmorelightthanusualwhenreading?

EARSANDHEARING

Yourelderlypatientshearingmaybeaffectedbygradualirreversiblehearinglossofnospecific
pathologicorigin(presbycusis),commonamongelderlypersons.

RESPIRATORYSYSTEM

Remember,shortnessofbreathduringphysicalactivitycouldbenormal.Eveniftheshortnessofbreath
hasincreasedrecently,thiscouldbenormal.Awarningofproblemscouldbeiftheshortnessofbreath
hascomeonsuddenly.Ifyourpatienthastroublebreathing,exploretheprecipitatingcircumstances.
Doesheorshecoughexcessively?Doesthecoughproducemuchsputum,perhapsbloodinthe
sputum?Agingcanalsoaffectthenose.Yourpatientmayreportsneezing,arunnynose,anda
decreasedsenseofsmellorbleedingfrommucousmembrane.

CARDIOVASCULARSYSTEM

Morethanhalfofallelderlypeoplesufferfromsomedegreeofcongestiveheartfailure.Askyour
patientwhetherhe/shehasgainedweightrecentlyandifhis/herbeltsorringsfeeltight.Inaddition,
findoutifhe/shetiresmoreeasilynowthanpreviously.Askifhe/shehastroublebreathingorifhe/she
becomesdizzywhenrisingfrombedorfromachair(Stosky1968).

GASTROINTESTINALSYSTEM

Anelderlypatientmaycomplainaboutproblemsrelatedtohisorhermouthandsenseoftaste.For
example,he/shemayexperienceafoultasteinhismouthbecausesalivaproductionhasdecreasedand
mucousmembraneshaveatrophied.Ifhe/shehasdentures,findouthowcomfortabletheyareand

43

howwelltheywork.Anelderlypersonssenseoftastedecreasesgradually.Thismaybewhyyour
patientreportsthathis/herappetitehasdecreased,orthathe/shecravessweeterorspicierfoods.

Anelderlypatientmayalsohavenonspecificdifficultyinswallowing.Carefullyassessthepossible
causesofregurgitationorheartburn.

*Askifhe/shehasthesamedegreeofdifficultyswallowingsolids/liquids.

*Askiffoodlodgesinhis/herthroatuponswallowing.

*Doesheorsheexperiencepainaftereating,orwhilelyingflat?

Alsoquestionhimaboutlongtermorrecentweightloss,rectalbleeding,alteredbowelhabits(Goldman
1991).

Energymetabolism,caloricintakeandphysicalactivityofaging.InCaristonLA(ed.):NutritioninOld
Age(XsymposiumoftheSwedishNutritionFdn.)Uppsala:AlmqvistandWiksell.

44

FEMALEREPRODUCTIVESYSTEM

Includequestionsaboutmenopausefortheelderlyfemale.Askwhenmenopausebeganandended(if
ended).Askwhatsymptomssheexperiencedandhowshefeltabouttheprocess.Askherwhethershe
isnowtakingestrogenreplacementtherapyorinthepast.Ifso,askforhowlongandthedosage.Be
suretoquestionanelderlyfemalepatientaboutsymptomsofbreastdisease.Findoutifsheregularly
performsabreastselfexamination,ifsheisphysicallycapableofdoingso.

NERVOUSSYSTEM

Inquireaboutchangesincoordination,strengthorsensoryperception.Doesthepatienthave
headachesorseizuresoranytemporarylossesofconsciousness?Hasheorshehadanydifficulty
controllingbowelorbladder(Tom1976).

BLOODFORMINGANDIMMUNESYSTEMS

Rememberthatanemiaiscommonamongolderpeopleandmaycausefatigueorweakness.The
immunesystembeginstodeclineatsexualmaturityandcontinuestodeclinewithage.Anelderly
personsimmunesystembeginstoloseitsabilitytodifferentiatebetweenselfandnonself.The
incidenceofautoimmunediseaseincreasesintheelderly.Theimmunesystemalsobeginslosingits
abilitytorecognizeanddestroymutantcells.Thisinabilitypresumablyaccountsfortheincreased
incidenceofcanceramongolderpersons.Decreasedantibodyresponseintheelderlymakesthem
moresusceptibletoinfection.Tonsilaratrophyandlymphadenopathycommonlyoccurinolder
persons.

Totalanddifferentialleukocytecountsdontchangesignificantlywithage.However,somepersonsover
age65mayexhibitaslightdecreaseintherangeofnormalleukocytecount.Whenthishappens,the
numberofBcellsandtotallymphocytesdecreases.TheTcellsdecreaseinnumberandbecomeless
effective.Asapersonages,fattybonemarrowreplacessomeactivebloodformingmarrow.This
occursfirstinthelongbonesandthenintheflatbones.Thealteredbonemarrowcannotincrease
erythrocyteproductionasreadilyasbeforeinresponsetosuchstimuliashormones,anoxia,
hemorrhageandhemolysis.Withage,vitaminB12absorptionmayalsodiminish,resultinginreduced
erythrocytemassanddecreasedhemoglobinandhematocrit.

TABLEII

Certaindisorderscommonlyaffecttheelderly.Whenreviewingyourelderlypatientssystems,notethe
followingpossiblypathologicalsignsandsymptoms:

SKIN: Delayedwoundhealing,changeintexture

NAILS: Brittleness,clubbing,pitting

HEAD: Facialpainornumbness

45

EYES: Diplopia,tunnelvision,haloeffect,glaucoma,cataracts

EARS: Excessivewaxformation,useofwaxsofteners

NOSE: Epistaxis,allergicrhinitis

MOUTH/THROAT:Soretongue,problemswithteethorgums,gumsbleedingatnight,hoarseness

NECK: Pain,swelling,restrictedrangeofmotion.

RESPIRATORY:Tuberculosis,difficultyorpainfulbreathing,excessivecoughproducing

excessiveorbloodstreakedsputum.

BREASTS: Discharge,changeincontour,nipples,gynecomastia,lumps.

CARDIOVASCULAR:Chestpainonexertion,orthopnea,cyanosis,syncope,fatigue,murmur,legcramps,

varicosities,coldnessornumbnessofextremities,hypertension,heartattack.

RENAL: Flankpain,dysuria,polyuria,nocturia,incontinence,enuresis,hematuria,renal

orbladderinfectionsorkidneyorbladderstones.

REPRODUCTIVE:MaleHernia,testicularpain,prostaticproblems.

FemalePostmenopausalproblems(bleeding,hotflashes).

ENDOCRINE: Goiter,tremor

MUSCULOSKELETAL:Pain,jointswelling,crepitus,restrictedmotion,arthritis,gout,lumbago,

amputations.

NERVOUS: Memoryloss,lossofconsciousness,nervousness,insomnia,changesinemotionas,

tremors,muscleweakness,paralysis,aphasia,speechchanges,numbness.

PSYCHOLOGICALASSESSMENT

Whenyouassessthepsychologicalstatusofanelderlypatient,rememberthatheorsheisprobably
dealingwithcomplexandimportantchangesatatimeinhis/herlifewhenhis/herabilitytosolve
problemsmaybediminishing.Ifhe/shetendstocopewellwithstressandviewsagingasanormalpart
oflife,he/sheshouldbeabletoadjustsmoothlytothechangesthatagingbrings.

Commonpsychologicalproblemsamongelderlypatientsincludeorganicbrainsyndrome,depression,
grieving,substanceabuse,adversedrugreactions,dementia,paranoiaandanxiety.Ofcoursethese
problemsarenotlimitedtotheelderlypatients.Theirincidence,however,ismuchhigherinthisage
groupthaninallotheragegroups.

46

1. ORGANICBRAINSYNDROME
OrganicBrainSyndromeisthemostcommonformofmentalillnessintheelderlypopulation.It
occursinbothanacuteform(reversiblecerebraldestruction)andachronicform(irreversible
cerebralcellulardestruction).Characteristicsofbothtypesincludeimpairedmemory(especially
recentmemory),disorientation,confusionandpoorcomprehension.

Intheelderlyperson,acuteorganicbrainsyndromemayresultfrommalnutrition,
cerebrovascularaccident,drugs,alcoholorheadtrauma.Restlessnessandafluctuatinglevelof
awareness,rangingfrommildconfusiontostupor,maysignalthiscondition.

Thecauseofchronicorganicbrainsyndromeisunknown.Themajorsignsofthisdisorder
includeimpairedintellectualfunctioning,poorattentionspan,memorylossusingconfabulation
andvaryingmoods.

2. DEPRESSION
Depressionisthemostcommonpsychogenicproblemfoundinelderlypatients.Sincethe
symptomsofdepressionspanawiderange,consideritasapossibilityinanyelderlypatient.
Depressionmayappearas:
A.changesinbehavior(apathy,selfdepreciation,anger,inertia).
B.changesinthoughtprocesses(confusion,disorientation,poorjudgment).
C.somaticcomplaints(appetiteloss,constipation,insomnia).

Ifyouobserveanyofthesesigns,questionyourpatientindetailaboutrecentlosses.Alsofind
outhowheorsheiscopingwiththoselosses.Assesstheirfeelingscarefully.Rememberthatan
elderlypatientsattitudetowardhis/herownaginganddeathandtowarddeathanddyingin
generalwillaffecthis/herchancesforsuccessfultreatmentofdepression.

Acommondifficultyelderlypatientsfaceisadaptingtoloss.Thegrievingprocessregularly
intrudesontheirlives.Yourpatientmayhavetodealwithlosingajob,income,friends,family,
healthorevenhishome.

Theselossesandassociatedfeelingsofisolationandlonelinesscancausestressthathas
physiologicalandpsychologicconsequences.Forexample,thelossofaspouseorotherloved
onecantriggerprofoundsorrow.Theresolutionofthismaybedifficult.Unsuccessful
resolutionofgriefcancauseapathologicgriefreaction.Thisreactionmaytaketheformof
physicalormentalillness.

Manyelderlypeopletodayareturningtosubstanceabuseandsuicideinresponsetosevere
stress.Suspectpossiblesubstanceabuseorthoughtsofsuicideifyourpatientistakingan
unusualamountofmedications.Alsoobserveforsuchsignsofalcoholabuseasjaundiceand
tremor.

47

 CLINICALDEPRESSIONINTHEELDERLY(Gerontology1991)
Depressionhasbeenshowntobethemostfrequentcauseforhospitalizationintheelderly.The
nursemustbeabletounderstandandthencopewiththisverycommonailmentinourelderly
population.Thedepressedelderlymanorwomanrepresentsaverychallengingnursing
problem.Depressionintheelderlyoftenmanifestsitselfasavarietyofsymptoms,both
physicalandemotional.Thislifethreateningdisordershouldbetreatedaggressively;andthe
nursecancertainlyplayanimportantroleintheoveralltreatmentplanfortheelderlyclient1.

DepressionisdefinedbytheDiagnostic and Statistical Manual of Mental Disorders of the
American Psychiatric Association,asapersistentlydysphoricandsadmoodwithlossof
pleasureinusualpastimes.Muchofthechronicdisabilityintheelderlycanberelatedto
depression.

Manyresearchersclaimthat25to30percentofthepopulationover65yearsofagesufferfrom
symptomsofclinicaldepression.Someresearchershavealsoconcludedthattheelderlytendto
havemorefrequentrecurrenceofdepressiveepisodes;andthatsymptomstendtobemore
severeintheelderly.However,asthepersonages,itisincreasinglydifficulttoidentifyand
diagnosesthiscondition.

Personsovertheageof65willvaryoftensufferfrompolypharmacy,increasingnumberof
illnesses,morepersonallossesandmorenutritionalchanges.Retirement,lossofstatus,family
lossesandotherconditionsseenintheelderlymayleadtoanincreasedriskofdepression
which,aswestated,isoftendifficulttodiagnose.

Again,hereiswherethenursemayplananimportantrole.Beawareoftheclientwhocomesto
thedoctorwithsymptomsofinsomnia,anorexia,constipationandfeelingsofuselessness.
Thesemayoftenberegardedasmerelyphysicalsignsofaging.Thenursemayfurtherassess
theclientanddeterminewhetherornotthepatientmayhaveanunderlyingdepression.Many
timesmedicationsareprescribedfortheseminorsymptoms.Beawarethatsomeofthese
medicationsprescribedfortheseillnessescanactuallycausedepressionintheelderlyperson.
Steroids,antihypertensivedrugs,anticonvulsants,antiinflammatorydrugs,antihistamines,
cytoxicdrugsandmanyotherdrugsmayactuallycausedepression.

Assessmentofdepressionintheelderlyisthemostimportantaspectofthenursingcare.An
importantpartoftheassessmentisthenursinghistory.Besuretotakeacompletepsychosocial
historyfromthepatientand/orthefamily.

Thistexthasanexcellentassessmenttoolforthepsychosocialareas.Besuretoassessthe
psychosocialhistorythatincludesthepersonsnormalcharacteristicsandthose
characteristicsthatthepersonisnowexperiencing.Thenurseneedstodifferentiatebetweena
normalbluespellandadeepdepression.Symptomsthatpersistfortwoweeksormoreare
signsofaseveredepression.Besuretocompleteathoroughphysicalassessmentaswellasthe

48

 psychosocialareas.Assessdiet,skin,hygiene,eliminationpattern,sleeppattern,exercise
pattern,medicationhistoryandemotionaldiscomfort.Theassessmenttoolinthistextincludes
alloftheseaspects.

Depressedpersonsarelikelytoignorehygiene.Thiscanleadtoskinproblemsandskin
breakdown.Constipationisacomplaintoftenseeninthedepressedclient.Insomniais
probablythemostcommonsleepproblemseeninthedepressedperson.Lookforthesesigns
andsymptomswhenperformingyournursingassessment.Also,begintoassessforthebarriers
totreatmentofthedepressedpatient.Beawareofthepatientsattitudestowardmental
healthservices.Veryoften,theolderpersonhasverysetideasregardingthehealthcaresystem
andcaregivers.Theymightbeafraidofthedoctororthenurseforfearofbeinglabeledas
crazy.Alsoobservetheirreactiontostrangers(thenurse).Manyelderlypersonsarevery
fearfuloftrustingstrangers,evenifthestrangeristheirnurse.Youmightwishtodeterminethe
typeofhealthinsurancethepersonhas.Theirfinancialpositionmanytimeswilldictatetheir
reluctancetoseektreatment.Bealerttotheseandothersuchsituationsthatmightbean
obstacletotreatment.Lateroninthehospitalizationthesefactorsmayplananimportantpart
ofthetreatmentplan.

Finally,thetreatmentofdepressionintheelderlywillusuallyinvolvesometypeof
psychotherapyand/orcounseling.Rememberthatdepressionintheelderlycanbeveryserious.
Symptomsofdepressioncanbeseriousenoughtoleadtothedeathofthepatient.Besurethat
yourfacilitycanprovidethetypeofservicesneededbytheseverelydepressedpatient.Many
facilitieslackthenecessarytrainedstafftodealwithseverelydepressedpatients.Your
assessmentcanbeveryimportant.Yourassessmentmightleadyoutoinformthedoctorthat
thisclientisverydepressedandneedsaggressivetreatment2.

Rememberthatdepressionintheelderlycanbelifethreatening.You,asthenurse,needtobe
awareofhowdepressiondevelopsintheelderlyandthesignsandsymptoms.Oneofthe
nursingresponsibilitiesistoeducatethehealthcareworkersatyourfacility.Everyoneonthe
healthcareteammustbeabletorecognizedepressionandtoalertthepatientsphysician.You
alsoneedtoknowhowtotaketheappropriateaction;andtakeitquickly,ifweasnursesare
goingtoprovidethebestpossiblecaretothedepressedelderlypatients.

1Wewillusethetermclientandpatientalmostinterchangeably.Weunderstandthatthetermsclientandpatienttendtobeused

differentlyindifferentpartsofthecountry.Intheeditorsopiniontheseterms,inthistext,canbeusedinterchangeable.


3. ADVERSEDRUGREACTIONS
Whenyouassessanelderlypatient,considerthathis/herpsychologicalproblemsmayresult
fromundetectedadversedrugreactions.Theincidenceofthesereactionsincreasesinolder
peoplebecausetheyusemoredrugs.Theyalsomaynottakemedicationsintheprescribed
manner.Physiologicchangesrelatedtotheagingprocessalsomayalterapatientsreactionto
drugs.Suchroutinelyprescribedmedicationsastranquilizersandbarbituratescancauseor

49

 increasedepression.Othermedications,includinganticholinergicsanddiuretics,maycause
confusioninelderlypatients.Alwaysincludeadetaileddrughistoryinyourpsychological
assessment.

4. PARANOIAINTHEELDERLY
Paranoiaisdefinedasanunreasonablefearthattheyareindanger.Paranoiamaybeone
symptomofpsychosis,depressionordementia.Itcanalsobeadiscreetillness,characterizedby
aslow,gradualdevelopmentofarigiddelusionalsysteminapatientwhootherwisehasclear
thoughtprocesses.

Ifyoudetectsignsofparanoiaduringthementalstatusexamination,trytodeterminewhether
theyarearesultofsensorylossproblems(whichmaybecorrectedbyglassesorahearingaid),
psychologicalproblemsorarealisticfearofattackorrobbery.Makecertainthatyouruleout
thepossibilitythattheparanoiaisjustified.Intodayssociety,manyelderlyareinfearoftheir
lives.Insomecasesthismaybetrue.Crimehasbecomesoprevalentandviciousthatthenurse
mustmakeadecision.Isthispersonsfearjustified?Oraretheyparanoid?

2Thetermaggressivetreatmentmeansthatthepatientneedsintensivetreatment.He/shemightneedpowerfuldrugsorpowerfultreatments;

buthe/shealsoneedstobeobservedcarefully.

5. THEEFFECTSOFANXIETY
Inanelderlypatient,theneedtoadjusttophysical,emotionalandsocioeconomicchanges(such
ashospitalization,lonelinessormovingtoanewneighborhood)cancauseanacuteanxiety
reaction.Thesechangesmayraisetheanxietyleveltothepointoftemporaryconfusionand
disorientation.Oftenanelderlypersonsconditioncanbemislabeledassenilityorasorganic
brainsyndrome.Actuallytheconditionshouldbeconsideredapsychogenicdisorder(Tom
1976).

6. DEMENTIA
Dementiaisthelossofintellectualabilities,especiallythosehigherorderfunctionsmeasuredby
memory,judgment,abstractthinkingandvisualspatialrelations,inthecontextofpreserved
alertness.Dementiaisdifferentfromdelirium,whichisacloudingofconsciousnesswith
decreasedawarenessofbothexternalandinternalenvironmentandadecreaseintheabilityto
sustainattentionmanifestedbydisorderedthinkingandagitation(Wetle1982).

DEMENTIA DELIRIUM
A. Developsslowly A.Developsabruptly
B. Progressive B.Nonprogressive
C. PresentformanymonthsoryearsC.Shortduration
D. Rarelyalteredconsciousness D.Fluctuatingconsciousness
E. Uncertaindateofonset E.Preciseonset

50

 Fifteenpercentofpersonsover65havesomedegreeofdementia.Lessthan5percentare
severelyimpairedduetodementia.Therearemanytermsthatarecommonlyinterchangedby
thepublic.Thenursemustbesuretousethecorrectterminologyafterassessingthecondition
ofthepatient.Thesetermsoftenusedinterchangeablyare:seniledementia,primaryneuronal
degeneration,chronicbrainsyndrome,Alzheimersdiseaseandprimarydegenerativedementia.

Oncetheconditionhasbeenaccuratelydiagnosedbythephysician,thetreatmentplancanbe
settomosteffectivelydealwiththeproblem.Manytimestheunderlyingproblemis
Alzheimersdisease.OthertimesthediagnosiswillbeParkinsonsorotherdiseaseconditions.
Whicheveristhecase,thenursingresponsibilityistoaccuratelyassessandreporthistoryand
symptomsoftheillnessinordertoexpeditethecorrecttreatmentplan.

SeniledementiainducedbyAlzheimersdiseaseisusuallyslowinonset.Womenaremoreoften
affectedbythistypeofdementiathanaremen.Thepatientstendtobeofadvancedyearsand
theAlzheimersdementiahasaslowlinearprogression.Thesepatientstendtohaveaflat
affect(showlittleemotion)andnootherorganicdiseaseconditionscanbeidentified(theyare
ruledoutbylabtestsadbyexamination).Mostothertypesofdementia(frombraindisorders)
tendtoafflictyoungeroldpeopleandusuallyhaveanabruptonset.

NUTRITIONALASSESSMENT

1. NORMALAGINGCHANGES
Agingischaracterizedbythelossofsomebodycellsandreducedmetabolismofothers.These
conditionscauselossofbodilyfunctionandchangesinbodycomposition.Adiposetissuestore
usuallyincreaseswithage.Leanbodymassandbonemineralcontentsusuallydecreasewith
age.

Apersonsprotein,vitaminandmineralrequirementsusuallyremainthesameasheorshe
ages.Whereascaloricneedsoftheelderlyaredecreased.Decreasedactivitymaylowerenergy
requirementsabout200caloriesperdayformenandwomenaged51to75;400caloriesper
dayforwomenovertheageof75;and500caloriesperdayformenovertheageof75.

Otherphysiologicchangesthatcanaffectnutritioninanelderlypatientinclude:
A. Decreasedrenalfunction,causinggreatersusceptibilitytodehydrationandformationof
renalcalculi.
B. Lossofcalciumandnitrogen(inpatientswhoarenotambulatory).
C. Decreasedenzymeactivityandgastricsecretions.
D. Decreasedsalivaryflowanddiminishedsenseoftaste,whichmayreducethepersons
appetiteandincreaseconsumptionofsweetandspicyfoods.
E. Decreasedintestinalmotility.
2. PATIENTHISOTRY
Disabilities,chronicdiseasesandsurgicalprocedures(forexample,gastrectomy)commonly
affectanelderlypatientsnutritionalstatus,therefore,tobesuretorecordtheminyourpatient

51

 history.Drugorsubstancestakenbyyourpatientforamedicalconditionmayalsoaffect
nutritionalrequirements.Forexample,mineraloil,whichmanyelderlypersonsusetocorrect
constipation,mayimpairgastrointestinalabsorptionofvitaminA.

Somecommonconditionsfoundinelderlypersonscanaffectnutritionalstatusbylimitingthe
patientsmobility.Therefore,theabilitytoobtainandpreparefoodorfeedhimorherselfcould
becompromised.Amongsuchdisordersareconditionssuchasdegenerativejointdisease,
paralysisandimpairedvision(fromcataractsorglaucoma).

Gastrointestinalcomplaints,especiallyconstipationandstoolincontinence,commonlyoccurin
olderpatients.Adecreaseinintestinalmotilitycharacteristicallyaccompaniesaging.
Constipationmayalsoberelatedtopoordietaryintake,physicalinactivityoremotionalstress.
Constipationmayalsooccurasasideeffectofcertaindrugs.Elderlypatientsoftenconsume
nutritionallyinadequatedietsconsistingofsoft,refinedfoodsthatarelowinresidueanddietary
fiber.Laxativeabuse,anothercommonprobleminelderlypatients,resultsintherapid
transportoffoodthroughthegastrointestinaltractandsubsequentdecreasedperiodsof
digestionandabsorption.

Socioeconomicandpsychologicalfactorsthataffectnutritionalstatusincludeloneliness,decline
oftheelderlypersonsimportancetothefamily,susceptibilitytonutritionalquackeryandlack
ofmoneytopurchasenutritionallybeneficialfoods.

3. ASSESSMENTTECHNIQUES
Currently,theadultstandardsfornutritionalassessmentareusedfortheelderly.These
standards,however,arenotasreliablefortheelderlyagegroup.Furtherresearchisneededto
developtoolsforassessingthenutritionalrequirementsofelderlypersons.

Measuresyoucanusetoassesssuchapatientsnutritionalstatusinclude:
A. Commonsense.
B. Considerationoffactorsthatplaceanypatientatnutritionalrisk.
C. Thedietaryhistory.
D. Yourobjectivedata(keepingtheirlimitationsinmind).
E. Monitoringofthepatientsintake(ifhospitalized).

Remember,proteincaloriemalnutritionisamajornutritionalprobleminpatientsover75years
ofageandcontributessignificantlytothisagegroupsmortality(Goldman1971)(Health
AssessmentHandbook1992).

52

 MUSCULOSKELETALSYSTEM

1. SPECIALHISTORYQUESTIONS
Biographicaldataaresignificantfortheelderly,becauseosteoporosiscommonlyoccursafterthe
ageof50.

Ifyourpatientschiefcomplaintispainassociatedwithafall,determineifthepainprecededthefall.
Painpresentbeforeafallmayindicateapathologicalfracture.Also,askifyourpatienthasnoticed
anyvisionorcoordinationchangesthatmaymakehimorhermoresusceptibletofalling.

Whenrecordingthepatientspasthistory,determineifheorshehashad:

a. Asthma(treatmentwithsteroidscanleadtoosteoporosis).
b. Arthritis(whichproducesjointinstability).
c. Perniciousanemia(inadequateabsorptionofvitaminB12inperniciousanemialeadstoloss
ofvibratorysensationandproprioception,resultinginfalls).
d. Cancerofthebreast,prostate,thyroid,kidneyorbladdermaymetastasizetobone.
e. Hyperparathyroidismleadstobonedecalcificationandosteoporosis.
f. Hormoneimbalancecanresultinpostmenopausalosteoporosis.

Duringtheactivitiesofdailylivingportionofthehistory,askyourpatientifhe/she
decreasedhis/heractivitiesrecently.Inactivityincreasestheriskofosteoporosis.Also,askyour
patienttodescribehisorherusualdiet.Elderlypersonsoftenhaveaninadequatecalcium
intake,whichcancauseosteoporosisandmuscleweakness.

2.PHYSICALEXAMINATIONFINDINGS

Yourexaminationoftheelderlyindividualwithasuspectedmusculoskeletaldisorderisthe
sameasforayoungeradult.However,olderpatientsmayneedmoretimeorassistancewith
suchtestsasrangeofmotionandgaitassessment.Thisisduetomuscleweaknessand
decreasedcoordination.

Disordersofmotorandsensoryfunction,manifestedbymuscleweakness,spasticity,tremors,
rigidityandvarioustypesofsensorydisturbancesarecommonintheelderly.Damagingfalls
mayresultfromdifficultyinmaintainingequilibriumandfromuncertaingait.

Besuretodifferentiategaitchangescausedbyjointdisability,painorstiffnessfromthose
causedbyneurologicimpairmentoranotherdisorder.Bonesofteningfromdemineralization
(senileosteoporosis)causesabnormalsusceptibilitytomajorfractures.Mostpatients,overthe
ageof60,havesomedegreeofdegenerativejointdisease.Thiscancausejointpainandlimits
spinalmovement(HealthAssessmentHandbook1987)(Stosky1968).

53

 ENDOCRINESYSTEM

1. ENDOCRINESIGNSANDSYMPTOMS

Manyendocrinedisorderscausesignsandsymptomsintheelderlythataresimilartochanges
thatnormallyoccurwithaging.Forthisreason,thesedisordersareeasilyoverlookedduringthe
assessment.Inanadultpatientwithhypothyroidism,forexample,mentalstatuschangesand
physicaldeterioration,includingweightloss,dryskin,andhairloss,occur.Yetthesesamesigns
andsymptomscharacterizethenormalagingprocess.

Otherendocrineabnormalitiesmaycomplicateyourassessmentbecausetheirsignsand
symptomsaredifferentintheelderlythaninotheragegroups.Hyperthyroidism,forexample,
willusuallycausenervousnessandanxiety,butafewgeriatricpatientsmayinsteadexperience
depressionorapathy(aconditionknownasapathetichyperthyroidismoftheelderly).In
addition,anelderlypatientwithGravesDiseasemayinitiallyhavesignsandsymptomsof
congestiveheartfailureoratrialfibrillationratherthanclassicmanifestationsassociatedwith
thisdisorder.
2. NORMALVARIATIONSINENDOCRINEFUNCTION

Averycommonandimportantendocrinechangeintheelderlyisadecreasedabilitytotolerate
stress.Themostobviousandseriousindicationofthisdiminishedstressresponseoccursin
glucosemetabolism.Normally,fastingbloodsugarlevelsarenotsignificantlydifferentinyoung
andoldadults.However,whenstressstimulatestheolderpersonspancreas,thebloodsugar
concentrationincreaseisgreaterandlastslongerthaninayoungeradult.Thisdecreased
glucosetoleranceoccursasanormalpartofaging.Therefore,keepthisfactinmindwhenyou
areevaluatinganelderlypatientforpossiblediabetes.

Duringmenopause,anormalpartoftheagingprocessinwomen,ovariansenescencecauses
permanentcessationofmenstrualactivity.Changesinendocrinefunctionduringmenopause
variesfromwomantowoman.However,estrogenlevelsusuallydiminishandfollicle
stimulatinghormoneproductionincreases.Thisestrogendeficiencymayresultineitherorboth
oftwokeymetaboliceffects;coronarythrombosisandosteoporosis.Remember,too,that
somesymptomscharacteristicofmenopause(suchasdepression,insomnia,headaches,fatigue,
palpationsandirritability)mayalsobeassociatedwithendocrinedisorders.Inmen,the
climactericstagecausesadecreaseintestosteronelevelsandinseminalfluidproduction.

54

CHAPTER IV


THE
NURSEPATIENT
HELPING
RELATIONSHIP

55

 THEHELPINGRELATIONSHIPWITHNURSEANDPATIENT

1. ROLESOFTHENURSE
Asyouusethenursingprocessdailywiththepatientorfamilyinlatermaturity,youwillbe
functioninginavarietyofnursingroles.Youwillberesponsibleforphysicalcare,technical
proceduresandforcreatinganenvironmentthatissafe,comfortable,stimulatingandhealth
promoting.Youwilloftenbecalledupontoteachinformallyandformallytoenablethepatientor
familytomanageselfcare,learnabouthisorherillness,orresponsetoasituationorbettercope
withhis/hercondition.Referraltoothersourcesofhelpmaybenecessary,fornoonehealthteam
membercanmeetallthepatientsneeds.Youmayserveascounselorandyoucanalwaysserveas
asourceofemotionalandsocialstimulationandsupport.Dependinguponyourbehaviorandthe
seniorsneeds,youmaybeseenasaparentalfigure.

Allofusneedlovingcontactwithotherpeopleinordertostayhumaninthefullestsense.Fromthe
momentofbirth,theinfantcannotsurviveunlessheorsheiscaredforbythenurturingperson.
Likewise,theelderlypersoncannotsurviveeither,emotionallyorphysically,unlesssomeonecares
abouthimorher.Caringisessentialtoarelationship.

Howtheseniorreactstoyou,yourattitudes,appearanceandbehaviorwillbeinfluenced,atleast
initially,bypastexperienceswithpeople.Ifexperienceshavebeenpleasantwithothers,heorshe
willrespondmorequicklytoyourcaring.Ifhe/shehasprimarilyfeltanxietyandtensioninhis/her
contactwithothers,he/sheislikelytobedistant,torespondslowlyoreventonotrespondatall
andtellyoutogoaway.He/shemayalsotestyourintentionswithovertlyobnoxiousbehavior.
However,underlyingthisapparentrejectionofyou,thereisusuallyagreatneedforinterpersonal
contact.Knowingthisshouldstimulateyoutocontinuetoreachout,tocare.

Importantinthetotalcareofthesenioristheestablishmentandmaintenanceofarelationship.
Yourgoalsmaybelimitedbecauseyoucannotalwayschangethepersonspathologyandyou
cannotreversetheagingprocess.However,youcanhelphim/hertoacceptandunderstandhis/her
situation;helphim/hertofindmeaninginhis/herlifeandtoenjoypersonalgrowthfromthe
experience.Thistotalcareinvolvesnotonlyphysicalcare,butalsogenuineconcernforthe
patientsfeelingofselfworth,regardlessofsocialvaluesorcapacityforachievement.

Theelderlypatientpresentsthenursewithavarietyofchallengesanddilemmas.Themedical
problemsoftheelderlyareusuallyvarycomplexandrequireagreatdealoftimeandenergytohelp
solve.Theproblemsorobstaclesencounteredwithtreatingtheelderlyarenumerous.Society
holdsmanynegativeopinionsandbeliefsconcerningtheelderly.Thenursemustovercomethese
stereotypesandnegativebeliefsinordertoeffectivelytreatthepatient.

Theelderlypatienthascertainrightstomedicalandnursingcare.

Theserightsarethesameasanyotherpatient:

56


a. Therighttoassessment.
b. Therightofpersonalautonomy.
c. Therighttoparticipateinhealthcaredecisionmaking.

Theserightsindicatethattheelderlyhavetherighttobetreatedjustlikeanyotheradultpatient.
Theyarenottobetreatedlikebabies.Therearemanyaspectsoftheserightsthatareunder
controversytoday.Thisincludestherighttodie,qualityofcare,qualityoflife,Medicareand
financialaspects,withholdingtreatment,patientdignityandothers.Thenursewillcertainlyface
ethicalandmoraldilemmasinthenearfutureconcerningtheserights.Thenursewillhavetobe
awareoftheserightsandbeawareofcourtdecisionsaffectingthecareoftheelderlyinorderto
continueatherapeuticnursepatientrelationship.

Relationshipcanbedefinedasaninterpersonalprocessinwhichonepersonfacilitatesthepersonal
developmentorgrowthofanother.Theprocesstakesplaceoveraperiodoftime.Theprocess
involveshelpingtheotherpersontomature,tobecomemoreadaptive,moreintegratedandto
openhisorherownexperience;ortofindmeaninginhis/herpresentsituation.

Thenursepatientrelationshipresultsfromaseriesofinteractionsbetweenanurseandpatientover
aperiodoftime.Thenursewillfocusontheneedsandproblemsofthepersonorfamilywhile
usingthescientificknowledgeandspecificskillsoftheprofession.Thishelpingrelationship
developsthroughinterestin,encounterwithandcommitmenttotheperson.

2. CHARACTERISTICSOFTHEHELPINGPERSON
Thecapacitytobeahelpingpersonisstrengthenedbyagenuinedesiretoberesponsibleand
sensitivetoanotherperson.Inaddition,experiencewithavarietyofpeopleincreasesyour
awarenessofothersreactionsandfeelings.Thefeedbackyoureceivefromotherswillteachyoua
greatdealonboththeemotionallevelandcognitivelevels.

Characteristicsofahelpingpersoninclude:being
a. Congruent Beingtrustworthy,dependable,consistent
b. Unambiguous Avoidingcontradictorymessages
c. Positive Showingwarmth,caringandrespect
d. Strong Maintainingseparateidentityfrompatient.
e. Secure Permittingpatienttoremainseparate,respectinghis/her
needsandyourown
f. Empathetic Lookatpatientsworldfromhis/herviewpoint
g. Accepting Enablingpatienttochangeathis/herownpace
h. Sensitive Beingperceptivetofeelings,avoidingthreateningbehavior
i. Nonjudgmental DONTjudgethepatientmoralistically
j. Creative Viewingthepatientasapersonintheprocessofbecoming,
notbeingboundbyhis/herpast,andviewingselfintheprocess

57

 ofbecomingormaturingaswell(Rogers1976)

Thereareseveralmorecharacteristicsthatcorrelatehighlywithbeingeffectiveinahelping
relationship.Onecharacteristicisbeingopen,insteadofclosed,ininteractionwithothers.An
additionalcharacteristicisperceivingothersafriendlyandcapable,insteadofunfriendlyand
incapable.Anothercharacteristicisthatofperceivingarelationshipasfreeing,insteadof
controllinganother.

Establishingandmaintainingarelationshiporcounselinganother,doesnotinvolveputtingona
faadeofbehaviortomatchalistofcharacteristics.Rather,bothyouand,thepatientwillchange
andcontinuetomature.Asthehelper,youarepresentasatotalperson.Youblendpotentials,
talentsandskills.Youdothiswhileassistingtheelderlypatienttocometogripswithhis/herneeds,
conflictsandself(Rogers1976).

Workingwithanotherinahelpingrelationshipischallengingandrewarding.Youwillnotalways
haveallthecharacteristicsjustdescribed.Attimes,youwillbehandlingpersonalstressesthatwill
loweryourenergyandsenseofinvolvement.Youmaybecomeirritatedandimpatientwhile
workingwiththeelderlyclient.Acceptthefactthatyouarenotperfectandthatyouarealwaysin
theprocessofbecoming.

Analyzingyourbehaviorinrelationtothepersonorfamilycanhelpyoudetermineyoureffecton
themandcanhelpyoutobemoreeffective.Justasyouhelptheseniortodevelop,youwillalso
continuetoexpandyourpersonalitytobettergaintheabovecharacteristics.Asyouopena
panoramaofpossibilitiestoanother,yourownpotentialunfolds.Rememberthatthemost
importantthingyoucansharewithapatientisyourownuniquenessasaperson.

Nursingexperienceinitselfcanbringaboutacoolefficiency,anovertindifferenceandan
impersonalattitudeandenvironmentforthepatient.Thedistantbehaviorthatmayresultwhen
thenurseisnotrewardedbytheworksystemfordemonstratinghelpingcharacteristicsseemstobe
anoccupationalhazardofnursing.Yet,inanincreasinglymechanicalworld,wehavetoremain
humanandtreatourpatientsashuman(Pollak1976).

CHARACTERISTICSOFTHEHELPINGRELATIONSHIP

1. RAPPORT
Arelationshipbeginswiththeabilitytoestablishrapport,creatingasenseofharmonybetween
individuals.Inordertoestablishrapportquickly,youmusthavethefollowingsocialskills(Rogers
1976).

a. Awarm,friendlymanner,appropriatesmileandcomfortableeyecontact.
b. Abilitytotreattheotherasanequal,toeliminatesocialbarriers,toconveyacceptanceand
topromoteasenseoftrust.

58

 c. Abilitytofindacommoninterestorexperience.
d. Abilitytoshowakeen,sympatheticinterestintheother,togivehimorherfullattention,to
listencarefullyandtoindicatethereisplentyoftime.
e. Abilitytoaccuratelyadopthis/herterminologyandconventionsandtomeethim/heronhis
ownground.
2. TRUST
Trustisthefirmbeliefinthehonesty,integrity,reliabilityandjusticeofanotherpersonwithoutfear
ofoutcome,theinnercertaintythattheotherpersonsbehaviorispredictableunderagivensetof
circumstances(Rogers1976).

Thecapacitytodevelopatrustingrelationshipisbuiltuponyourattitudetowardpeople,your
flexibilityinrespondingandwhatyouarepersonally.Techniquesandknowledgearenotenough.
Youwilllearnthroughexperiencewhataspectsofyourpersonalityaremoreeffectivewith,and
helpfulto,others.

Trustisbaseduponconsistencyratherthancompatibility.Theseniorcannotrevealhimorherself
norshareimportantinformationunlesshe/shecanrelyuponyou.Hemustbelievethatyouwill
reactwiththesamebehavioralcharacteristicseachtimeheorshemeetswithyou.He/sheneedsto
knowthatyouwillkeepcontentfromtheinterviewconfidential,asmutuallyagreedupon.Youmay
havetodelayobtainingcertaininformationuntilasenseoftrustisestablished.Thisisbecausethe
elderlypatientmayfeelverythreatenedbyanintervieworexamination.Inaddition,youmustfeel
thatyoucanpredictthepersonsbehaviorbecauseyouhaveanunderstandingoftheperson
(Rogers1976).

3. UNCONDITIONALPOSITIVEREGARDANDACCEPTANCE
Twoqualitiesoftendescribedasessentialtoarelationshiparepositive,warmfeelingsand
acceptance.Isitpossibletogiveexpertandprofessionalcareandnotfeelpositivelytowardyour
patient?MostpatientswouldsayNO.Thehumanspiritlosesitssenseofvitalityandeventhe
willtolivewhensurroundedbyhostilepersons.

Realistically,itisnotpossibletolikeeveryone.Similarly,itisnotpossibletoestablishandmaintain
arelationshipwitheveryone.However,youwillfindsomepatientsyouwillbegenuinelyinterested
inandcanfeelaffectionfor.Likewise,othernurseswillrespondthesamewaytootherpatients.
Thereareafewcantankerousorrepulsivepeoplewhomnooneseemstofeelanyrapportwith
orinterestin.Perhapsyourwillingnesstoreachoutwillmakeadifference.Yourabilitytostimulate
amorelikablebehaviorinthatpersonmayalsomakeadifference.Alsoyourwillingnesstolearn
moreabouthisorheruniqueness,willbetheresultofourunconditionalpositiveregard,beliefin
thedignity,worthandimportanceoftheperson,regardlessofhisorherbehavior(Murray1980
(Pollak1976).

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4. EMPATHY
Unconditionalpositiveregardandacceptanceareeasiertoachieveifyouhavedeveloped
empatheticunderstandingofpeople.Empathyisfeelingwiththepersonandsimultaneously
understandingthedynamicsofhisorherbehavior.Asyouandtheseniorfeelandthinktogether,
yourfeelingsforhimorherimpelsyoutoact.

Empathyistheabilitytosensethepatientsprivateworldasifitwereyourown.Youcandothis
withouteverlosingtheasifquality.Youcansensethepatientsanger,fearorconfusionasifit
wereyourown.Youcandothiswithoutyourownfeelingsgettingboundupintheinteraction.

Youareempathetictothedegreethatyouareabletoabstractfromyourownlifeexperience,by
wayofrecallorgeneralizations,commonfactorsthatareapplicabletothepatientsproblems.

Certainqualitiesenhanceempatheticskills.Theabilitytoempathizevarieswiththepatient,time
andnurse.Certainly,ageneralinterestinpeople,basicknowledgeofhumanbehaviorandawarm,
flexiblepersonalityencouragesempathy.

Othercharacteristicsthatenableyoutobemoreempatheticare:
a. Similarityinvalues,experiences,socialclass,culture,economiclevel,religion,age,
personalityorsamenessofsex.
b. Abilitytobealert,tolistenwiththethirdear,tobecomeinvolvedinanother,to
abandonselfconsciousness.
c. Abilitytocopewithegocentricity,anxiety,fears,feelingsorstressesthatblock
listeningtoandfeelingwithanother.
d. Varietyoflifeexperiencesthathelpyoutoacquireabroadunderstandingofpeople,
flexibilityandspontaneity.
e. Abilitytomaintainanadequatehealthandenergylevel.
f. Abilitytointerpretcorrectlyandtoavoiddistortingperceptions.

Empathyinvolvesthefollowingdimensions:
a. Toneexpressingwarmthandspontaneitynonverballyandverbally.
b. Pacetimingremarksorbehaviorappropriatetothepatientsfeelingsandneeds.
c. Perceptionabstractingthecoreoressentialmeaningofpatientconcerns;
discussingthemwithhim/herinacceptableterms.
d. Leadingformulatingquestionsorstatementsthatmovetheinterviewinthe
directionofthepatientsconcerns.

Empathyisnotthesameassympathyorpity:

Thesympatheticpersonbecomesstrickenwithemotionbecauseheorsheprojectshimself
orherselfintotheotherpersonsplace.Theempatheticpersonsharestheexperiencebut
maintainsobjectivity.Thesympathizermaybesecretlyhappythatacertainsituationhas

60

 notoccurredtohim/her,orhe/shemayfeelguiltyinhis/herowngoodfortune.Empathy
canbefoundinanysituation,ingrief,injoy.

Pityiscontrarytohelping.Tocauseanothertofeellikeavictimdebasesthepersonright
now.Italsoconveysthathewillremaindebasedandhelpless.Pityconveysthattheother
personreceiveshelpbecauseyouareobligatedandpseudoaltruistic.Spontaneousand
genuinehelpingisoneononehumanbeingwithanother,simplybecauseyouareboth
human.

Howdoyoucommunicateempathy?Useverbalandnonverbalcommunicationsothatthe
seniorexperiencesafeelingofbeingunderstood.Yourstatementsserveasanemotional
mirrororasareflectionofhisorherfeelingswithoutdistortingorgivinghimorheradvice.
Forexample,youmaysay:ItseemsasifyouareverydiscouragedwithP.T.orItsounds
asifyouarequiteconcernedaboutwhetheryoumadearightdecision.Avoidaresponse
like,Iknowhowyoufeel.Sucharesponsemakestheseniorunsureaboutyourtruly
understandingofhim/her.Itisaroteresponseandisnotbasedonagenuine
understandingofhis/hercurrentfeelings.

Talkontheseniorslevelofunderstandingandadjustyourtoneofvoicetohisorhers.For
example,ifyouuseadeclarative,harshtoneofvoice,itwillseemasifyouaretellingthe
patientwhathe/shethinksandhowhe/shefeels.Thatisnotanexampleofreflecting
his/herfeelings.Usinglanguagethathe/shedoesnotunderstandwillconveyalackof
respect,regardlessoftheaccuracyofyourinterpretation.

Evaluatetheelderlypersonstruefeelings.Sometimeshe/sheisnotreadytoadmitcertain
feelingsandneedstimetodenythem.

Reflecttheseniorsfeelingsfrequentlyforcorrection,disapprovalorapproval.Remain
opentohis/herresponse.Apatientwhoisfreetocorrectyoumovesontoahigherlevelof
selfunderstanding.Ifhe/shecannotrefuteyourreflection,he/shethencanbuildup
defenses.Thisleadstowithdrawal,therebydefeatingtheprimarypurposeofthe
relationship.Someexamplesofhowtobeginyourreflectionsare:IfIunderstandyou
correctly,youfeel..oryoumightsay,Isthatright?.

Respondactivelyandfrequentlyenoughtothesenior,withoutinterruptinghim/her.This
indicatesthatyouarefocusingonhis/herspeechandfeelings.

Theultimatepurposeoftheempatheticresponseistoconveytothepersonadepthof
understandingabouthim/herandhis/herpredicamentsothathe/shecanexpandand
clarifyhis/herunderstandingofselfandothers.Thepatientreceivesrelieffromloneliness
andovercomesfeelingsofisolationandalonenesswithhisproblems.Yourwillingnessto
understandhowtheseniorfeelsabouthisorherworldimpliesthathis/herpointofviewis
valuable.Also,thefocusofevaluationiswithinthepatient,sothathebecomesless
dependentontheopinionsofothersandgrowstovaluehimorherself.Empathetic

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 understandingisnotapassiveprocess.Itwillnothappenwithouteffort.Youmust
concentrateintenselyontheperson.Intenseconcentrationallowsyoulittletimetoreflect
onpersonalneeds,valuesandideals.Itpreventsjudgmentalthoughtsorbehavior.

Improvementinpatientsconditionsiscorrelatedwithempatheticresponses,regardlessof
theirdiagnoses.Notonlyarehighempatheticlevelscorrelatedwithimprovement,butitis
foundthatlowlevelsofempathycontributetoincreaseddisturbanceinpatients.Thelack
ofempathydisplayedbynursescould,therefore,behinderingtheirpatientsrecovery.

5. GOALFORMULATION
Ahelpingrelationshipdiffersfromasocialrelationship.Inthehelpingrelationshipthereisexplicit
formulationofgoals.Youmayhavecertaingoalsthatyouhopetoaccomplish,buttheseniormust
activelyparticipatewithyouinsettingmutualgoals.Astherelationshipprogresses,newproblems
orconcernswillbeidentifiedandnewgoalswillhavetobeset.Therelationshipisstructuredinthat
yousharewiththepatientwhatheorshecanexpect.Youthenlistentowhatthepatientexpectsof
you.Togetheryoudeterminethecourseoftherelationship.Intentionsandexpectationsare
verballyandnonverballyconveyedtoeachother.Expectationswillusuallychangeasthe
relationshipprogresses.

Generalgoalsofthenursepatientrelationshipinclude:
a. Increasingtheseniorsselfesteemandpromotingapositiveselfconceptandsense
ofsecurity.
b. Decreasingtheseniorsanxietytoaminimum.
c. Providingagratifying,positiveexperience.
d. Assistingtheseniorinimprovingcommunicationskillsandinparticipating
comfortablywithothers.
e. Providingtheopportunityforthepersontogrowemotionally.
f. Helpingtheseniorfindmeaninginhis/herlifesituation.
g. Maintainingandstimulatingthepersonbiologically,mentally,emotionallyand
socially.
h. Gatherdatatogainindepthassessmenttoprovideindividualcare.
6. HUMOR
Intenseinteractionbetweentwoormorepeoplecannotendureunlessasenseofhumorsurfacesat
times.Humoristheabilitytoseetheludicrousortheincongruitiesofasituation,tobeamusedby
onesownimperfectionsorthewhimsicalaspectsoflife,toseethefunnysideofanotherwise
serioussituation.Humordoesnotnecessarilymeanjokingandteasing.Itdoesnotinvolvetheput
downofanotheranditdoesnotalwaysevokelaughter.Humormaybeexpressedasatinysmile
thatlingersorthementalchucklethatoccurswhenyouaresoberfaced.

Thepurposesofhumorinclude:
a. Releasingtension,anxietyorhostility.
b. Cautiouslydistractingfromsadness,cryingorguilt.

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 c. Decreasingsocialdistance.
d. Conveyingasenseofempathytoanother.
e. Expressingwarmthandaffection.
f. Encouraginglearningortaskaccomplishment.
g. Denyingpainfulfeelingsorathreateningsituation.

Theelderlypatientoftenhasexperienceduseofhumorbeneaththosesteelyeyesandtightlips.
Hemaytestyouwithafewdrystatementstoseeifyouarereallyalertandifyoucanmakethe
cognitiveconnectionsheinsinuates.Toooftenthesedrystatementsreceiveonlyagruntin
reply,orworse,theyareignoredandtheseniorislabeledsenile,confusedorcrazy.

Ifyoudonotrespondtohishumor,he/shelosesemotionalandsocialinputandselfesteem.
Althoughunderneathhe/shemayconsideryouhis/herinferiorlesseducated,less
experienced,lesswise.Youlosewhenyoucannotexpandyourmindwiththehumorous.You
dryupemotionallyandyouhavelostanopportunitytolearn,tomatureandtoenjoy.

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 CHAPTER V


THE
CHARACTERISTICSANDCRISESOF
LATERMATURITY

64

 COGNITIVECHARACTERISTICSINLATERMATURITY

1. STEROTYPES
Contrarytothestereotype,intellectualfunctioningdoesnotautomaticallydegenerateinlater
maturity.Assessmentandnursingcaremustbedirectedtowardthehealthycharacteristicsaswell
astowardanylimitationsthatmightbepresent.

Chronologicalageisrarelyareliableindexoftheelderlypersonsmentaldevelopment.Theinitial
levelofabilityiscrucial.ThosepersonswithhighIQscoresaschildrenshowprogressivegainsin
generalinformation,comprehension,vocabularyandarithmeticwhenretestedinlaterlife.Abright
20yearold,allthingsbeingequal,willusuallybeabright70yearold.Thisbright70yearoldwill
functionbetterincognitiveskillsthantheaverage20yearold.

Cognitivefunctionsrefertomentalandintellectualprocessesofdrive,perception,interest,
motivation,memory,reasoning,thought,learning,problemsolvingandjudgment.Thesefunctions
includetheabilitytoexamineasituation;takein,processandrecallinformation;orientselfintime
andplace;organizecomplexdata;andrespondappropriatelytostimuliincontent,emotionand
overtime.

2. PROBLEMSOLVINGABILITY
Thebrainpossessesatremendousreservecapacity.Perhapsthisiswhytheseniormaycopevery
welldespitethedecreaseoffunctioningnervecellsinthecentralnervoussystem.Thisdecreaseis
influencedbycellular,circulatoryandmetabolicchangesoccurringinthebodywithaging(Botwinick
1967).

Theolderpersonmaybeabletotolerateextensivedegenerationinthecentralnervoussystem
withoutseriousalterationofbehaviororcognitivefunctioninasupportivesocialenvironment.The
personoftenremainsrelativelyunimpairedbecauseheorshehasdevelopedwaystocounteract
slightmemorylossordifficultyinlearning.Certainsocialskillsorpleasantresponseshelphim/her
throughasituation.Therefore,othersmightnotnoticeaslightcognitivedeficit.Ifothers
responses,inturn,remainpositive,his/herselfconfidenceenablestheseniortouseskillshe/she
doespossess.Thus,dailyfunctioningislikelytobeunimpaired.Eveninunusualsituations,he/she
islikelytocomeupwiththebestsolutionforhimorherself.

Theinitiallevelofabilityiscrucialforcontinuedlearning.ThosewithhighIQscoresatayounger
ageareusuallybettertocopewithcurrentstresses,managenewsituationsorworkmore
effectivelyinfamiliarsituations.Infamiliarsituationstheycanuseavarietyofskillsthatare
enhancedbythoughtfulexperienceandmaturity.

Theelderlypersonislikelytobesuperiortotheyoungerpersoninoverallfactualknowledge;
coordinationoffactsorideas,lifeexperienceandwisdom;useofauthorityandpowertogetthings
doneandmaturityofjudgment.Allofthesecouldenhanceormaintainproblemsolvingabilityand

65

 workperformance.Yet,howthesenioruseshisorherskillstodoproblemsolvingmaydifferfrom
thatofayoungerperson.Theolderpersonperformsmoreaccuratelywhenstimuliarelogically
groupedandsequential;andmoreaccuratelywhengivenalargeramountofdata,insteadof
isolatedbitsofinformation.He/shealsodoesbetterwhengivenalongertimetoprocessthedata.
He/sheislikelytoworkoutmentallyhowtodosomethingbeforehe/sheactsitout.

Theseniorislesslikelytotakeadvantageofinformationthatisnotdirectlyrelevanttothesituation.
He/sheisunlikelytoacquirenewideasorconceptsunlesstheyarebetterthancurrentlyheldideas
orconcepts.Tasksthatrequiremakinganalogies,formingnewconcepts,ornewclassificationsand
findingnovelorcreativeanswersaremoredifficulttoperform.However,withenoughtime,the
seniorwouldcomeupwithaworkablesolutiontotheproblem.

3. CREATIVITY
Rigidityandconcretenessinthoughtaretypicalofoldage.Theolderpersonseemsmorerigidinhis
orherthinkingbecausehe/sheiscautionsandemphasizesaccuracyinsteadofspeed.Caution
resultsfromatendencytoavoidriskydecisions.Thisislikelyduetoafearoffailureorhe/shehas
learnedfrompastexperiences.Yet,whenadecisioncantbeavoided,theelderlywillchoosehigh
riskorinnovativesolutionsasareyoungerpeople.Theelderlyaremoreconcreteinthinkingand
strivetobefunctionalorpracticalinsteadofabstract.

Reduceuseofabstractionskillshasotherresults.Researchindicatesthatappreciationofjokes
increasesbutcomprehensionofsubtlecontentdecreasesinoldage.Paststudiesoncreativityand
productivity,measuredbypublicationsanddiscoveries,indicatedthatpeoplearemostcreative
betweentheagesof30to50.Actually,thereisnoagelimitforcreativity,sincecreativityisnot
limitedtopublicationsanddiscoveries.Thehumaniscreativeinvariousways.Currentresearch
indicatesthattheseniorisoftencreative,evenifhe/shehasnothadverymuchformaleducation.
He/sheusespastexperienceandinsightsinnewwaysinordertomeetcurrentsituations.He/she
usuallyintegratesexperienceonahigherlevelabsorbing,siftingandreconstructingrealityonhis
ownterms.Hetreatsashypothesiswhatmostpeopletreatasfact.Herecognizesthatanything
encounteredisincomplete,thatitisinneedoffurtherstudyandreflection.

Regardlessofhowcreativityisdefinedassuperiorqualityorastotalproductivitythepeaksand
declinesaretheresultofmorethanintellectualchanges.Willpower,workingstrength,endurance
andenthusiasmareallpartofcreativity.Withthetrendstowardlongereducationalpreparationin
manyfieldsofwork,futurestudiesmayrevealthatcreativityincreaseswithage,sincemanypeople
willbeolderbeforetheycanbecomeproductive.

4. REACTIONTIME
Reactiontimeusuallybecomesslowerasthepersonages.However,someolderpersons,especially
physicallyactiveseniors,reactasquicklyassomeyoungerpeople.Theseniorneedsextratimeto
performphysicaltasks.Performancescorestendtobelowerandareusedtoexplainintellectual
decline.Yet,bypracticingatask,theolderpersoncanlearntoimprovehisorherreactiontime.

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 Seniorsperformcertaincognitivetasksslowlydoto:
a. Decreasedvisualandauditoryacuity.
b. Slowermotorresponsetosensorystimulation.
c. Lossofrecentmemory.
d. Changedmotivation.

Heorshemaybelessinterestedincompetingintimedintellectualtests.Further,anapparently
shorterdurationofalpharhythminthebrainwaveaffectsthetimingofresponse.Reaction
timeisalsoslowerwhenthepersonsufferssignificantenvironmentalorsociallosses.Italsois
slowerwhenhe/sheisunabletoengageinsocialcontactandwhenhe/sheisunabletoplan
his/herdailyroutines.Theperson,whoisill,oftenenduresenvironmentalandsociallossesby
virtueofbeinginthepatientrole.Thus,he/shemaybeslowerrespondingtoyourquestionsor
requests(Murray1980).

Yet,sometestshaveshownthatmentalreactiontimebeginstodeclineafter26yearsofage.In
onestudy,adultswhowere71werecomparedwith43yearolds.Bothsetsofsubjectswere
giventhesametestforvigilanceorclockwatching.Seniorswerejustasattentiveandvigilantas
youngadultsfor45minutes.Afterthatperiod,lossofinterestandfatiguereducedtheirdegree
ofvigilance.However,anattentionspanof45minutesisacceptableinyoungadults,as
evidencedbythelengthofaclasshour(50minutes),inmostcolleges.

Reactiontimeisaffectedbypreexistingexpectationsforstimuliaswellasexpectationsduring
theexperiment.Theseniorismorelikelytoexpectchangeratherthanrepetitioninsequences.
Hehaddevelopedabitofagamblingattitudetowardlifeovertheyears.Thus,he/she
respondsfastertostimulithatarenotrepetitious.Mosttestsforreactiontimeinvolved
repetitiousstimuli,whichmayinfluencetestscores.

Thepersonover50performslessefficientlyintasksrequiringspeedorwhengivenlittle
advancetimetorespondtothetask.Theolderpersonhasalongerresponseinitiationtime,
especiallywhenhandmovementsareinvolved.He/sheusuallytakeslongertoconvertverbal
stimulitoamentalimage.Responseisslowerifactionmustbecarriedoutwithoutseeingwhat
isbeingdone,whenalargequantityofdataarepresentedinillogicalorder,whenaquantityof
evidencemustbeplacedtogetherwithoutusingmemoryaidssuchasnotesandwhen
abstractionsarepresented.Yetmanyyoungerpeoplealsohavedifficultyundersuch
conditions.

Theaverageelderlymanperformslessaccuratelyinfastpacedthaninslowpacedsituations.
Heislesslikelytotryinfastpacedsituationsunlessheissureoftheaccuracyofhisresponse.
Performanceoftheaverageelderlywomaniscomparabletothatofyoungerhighlyverbalmen
andwomeninfastpacedsituations.Throughoutlife,womenexcelinverbalabilityandfluency
tests.Olderwomenrespondmorereadilytocognitive,psychomotortasksthantoelderlymen.

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5. MEMORY
Memoryistheabilitytoretainorrecallpastthoughts,images,ideasorexperiences.Aprogressive
lossofmemorydoesnotnecessarilyoccurinlatermaturity,althoughmemorylossaffectsmore
peopleastheygetolder.Lossofshorttermmemory,recallforrecentevents,ismorelikelytooccur
thanlossofremotememory,recallforeventsthatoccurredinthepast.

Thepersonspermanentmemoryisanorganizednetworkofconceptsinterrelatedinspecificways.
Iftherelationshipbetweentheseconceptscannotbeusedbecauseofloss,decreasedretrievalor
loweraccess,thepersonlosesconceptualrichnessorspontaneoususeofmemorylinks.Suchlossis
morelikelytooccurinolderpeoplethaninyoungerpeopleandinpersonsinstitutionalizedthanin
personslivinginthecommunity,apparentlybecauseofthenumberoflifecrisesandlessintellectual
stimulationfortheformergroup.

Memorylossmayoccurforvariousreasons:
a. Interferencefromothermemoriesthatarevaluedbythepersonandaccumulated
withage.
b. Senseofworthlessnessordepression,sothatlessenergyisdirectedtowardrecall.
c. Lossofinterestincurrentevents;pastmemoriesaremorepleasant.
d. Neurochemicalandcirculatorychangesmayaffectcerebralfunction.
e. Lossofcellsinthecentralnervoussystem.
f. Difficultyininformationacquisitionbecauseofdeficiencyinneuralsynapsesinthe
storagesystem.

Shorttermmemoryiscentraltolearningprocessesthatwouldnototherwisedeclinewithage.
Synthesis,analysis,comparisonandabilitytoorganizecontentarelessdependentonshortterm
memory,andthesefunctionsdonotdeclinewithage.Theprobleminlearningoccursbecause
thepersonlosesthepiecesofimmediateinformationneededtoprocess,codeorsynthesis.
Shorttermvisualmemoryappearstobemoresusceptibletoagingthanisauditorymemory.

Theseniorhasdifficultyinorderingthetimesequenceofmorerecentevents,inrotememory
andinimmediaterecallofnewlearning.Heorsheusesfewermentalimagestoenhanceverbal
phraseshe/shehearsandtoactasmemorymediators,whichmayaccountforthepoorer
performanceonmemorytests.

Longtermorremotememory,includingvocabulary,personalhistory,pastexperienceandbasic
knowledge,ishighlyresistanttotheeffectsofnormalaging.

6. FACTORSTHATINFLUENCECOGNITIVERESPONSE
Manyfactorsmustbeconsideredwhenyouassesstheintellectuallevel,problemsolvingability,
creativity,reactiontimeormemoryoftheolderperson,includingthefollowing:
a. Interestinlivingandineventsabouthimorher.

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 b. Sensoryimpairmentsthatinterferewithintegrationofsensoryinputintoproper
perception.
c. Amountoftimesinceinschoolorinanintellectuallydemandingposition.
d. Educationallevel,pastinvolvementinlearningactivitiesorearliercognitive
incapacities.
e. Amountofdeliberatecaution;usingmoretimetoanswerordoatask,whichcanbe
interpretedasnotknowing.
f. Presenceofadaptivemechanismstoconserveenergyratherthanshowingassertion
ortimeconsciousness.
g. Degreeofmotivationtopleasethosearoundhimorherortoparticipateinatesting
situation.
h. Presenceofillhealth.

Previouslifestyle,presentbehaviorpatternsandgeneralcopingmechanismsallaffectcognitive
functionandmustbeconsideredinassessment.Observebehaviorinavarietyofsituationsand
listentothepersonsconversationandreminiscences.Talkwithfamilymembersorfriends.
Considerthetotal,uniqueindividualphysically,emotionallyandsociallysothatyoucanincrease
theaccuracyofyourcognitiveassessment.Toooftencognitiveimpairmentofthepersonin
latermaturityisconsideredasirreversiblebraindamageorchronicbrainsyndrome.Recent
researchindicatesthatmentalimpairmentmaybecausedbyanumberofinteracting
relationshipsofbiological,psychological,socialandenvironmentalfactors.Evenwhenbrain
damageispresent,impairmentmayrangefromslighttosevere.

7. EMOTIONALFACTORS
Someofwhatiscalledmentalimpairmentresultsfromourapproachtoolderpeople.Society
expectstheolderpersontobecomedeterioratedorsenile.Ifhisorherselfimageisaffectedbya
roleexpectationofmentaldysfunction,his/herbehaviorbecomessenile,anexampleoftheself
fulfillingprophecy.Institutionallifealsolimitsmotivationtobehaveappropriatelybecause
opportunitiesarenotusedtodrawoutfunctionsassumedtobelostinoldage.Theinstitutionis
oftendevoidoftimeandenvironmentalcues,andconfinementcausesdisorientationandconfusion.
Reactionsofothersmarkedlyaffectthepersonsmotivationtostayalert,tolearn,tobecreative.
Thepersonwhofeelsworthlessislesslikelytotry.

Thepersonwhosuffersmarkedlosses,especiallythelossofasignificantperson,tendstoperform
lessadequatelyonpsychometricandpersonalitytests.Oftengeneralbehaviorandproblemsolving
abilitiesarenoticeablylesseffectiveaswell.

Therelationshipamongthreecognitiveabilityfactors(abilitytoprocessinformation,manual
dexterityinresponsetostimuliandabilitytoanalyzepatterns),andthreepersonalitydimensions
(anxiety,extroversionandopennesstoexperience)wereexaminedinover900malesaged25to82
years.Persons,whowerehighlyanxious,scoredloweronallthreecognitiveabilityfactors.Persons
opentoexperience,scoredhigheronabilitytoprocessinformationandanalyzepatterns.

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 Introvertedpersonsscoredhigheronabilitytoanalyzepatternsthandidextroverts.Olderpeople
performedlesswellthanyoungeronesonmanualdexterityandabilitytoanalyzepatterns,butthey
didequallywellonabilitytoprocessinformation.

Theseniorismoreapprehensiveaboutnewlearningsituations,especiallyinacompetitive
atmosphere.Heanticipatesdifficultyinlearningnewtasksandasksformoredetailandspecific
directions.Certainlyquestionsshouldnotbeinterpretedasmentalincompetency.Theolder
personisusuallymorecautiousthantheyoungeradultbecauseofhis/herexperience,which
accountsinpart,forthedifferenceinexperimentaltestperformance.Wheneverpossible,tasksare
selectedthathavelessriskoratwhichthepersonhasahigherprobabilityofsuccess,probablyto
avoidanegativeselfevaluation.

8. SOCIALFACTORS
Ourculturevaluesarapidverbalandmotorresponse.Theolderpersonhasinternalizedthatvalue.
Becausehe/shecannotrespondrapidlytoaquestion,statementortask,he/shemaydevaluehimor
herself.Further,he/shemayhaveinternalizedtheculturalexpectationthatschoolisonlyfor
youngsters.Hence,he/shelacksconfidenceinpursuingformalorinformallearningactivities.
He/shemayconsiderhimorherselfandotherolderpeopletoostupidortooslowtolearn.

Theolderpersonshouldbeseenasaproductivepersonwhohasbeenlearningallofhis/herlife.
Anydeclineofmentalpowerismorelikelytoresultfromthebraingettingtoolittleratherthantoo
muchwork.Lackofenvironmentalstimulation,forcedisolationanddisengagementhastenmental
andphysicaldecline.Thepersonfeelslesslikemakingtheefforttorespondintellectually.Those
whocontinuetoworkhavemorenormalbrainfunctionandhavehigherintelligencetestscoresin
latermaturity,thandothosewhoareidle.Societyneedsthecognitivepotentialofoursenior
citizensandshouldprovideopportunitiesforthemtousetheirskills.

9. PHYSICALFACTORS
Sensoryimpairmentsthataccompanyagingcancausethepersontomisscertainstimuliandasa
result,appearintellectuallyimpaired.

Inonestudyofrelationshipbetweenvisualandmentalfunction,subjectsweredividedintothree
groupsonthebasisofvisualacuity:
a. Adequatevision.betterthan20/70
b. Lowvision...20/70to20/100
c. Legallyblind20/200orworse

Thegroupwithadequatevisionscoredhighestonthementalstatusquestionnaire.Lowest
scoreswereinthelegallyblindgroup.Thatmostolderpeoplecouldcooperatewithvisionand
mentaltesting,wasalsoshown.

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 Atthispoint,whethervisionlosscausesimpairedmentalfunctioningororganicbraindisease
causesimpairedvisionisunknown.Theyareprobablyinterrelated.Also,medications,general
physicalhealthandemotionalstate,canaffectbothvisualandmentalfunction.Adirect
relationshipalsoexistsbetweenhearinglossandreducedcognitiveeffectiveness.Hearingloss
resultsinchangedspeechperception,reducedabilitytodefineconcepts,todescribeabstract
relationshipsandeventorecallstoredinformation.Thus,hearinglossaffectscognitivetest
scores,reactiontimeandpersonality.

Ifthepersoncannotseeadequatelyorhearwhatyouaresaying,his/herresponsemayappear
confused,disorientedorstupidwhennoneofthesecharacteristicsispresent.Theproblemis
increasedifyouarespeakingEnglishandtheelderlypersonsfirstlanguageisnotEnglish.
Inabilitytodifferentiateamongenvironmentalstimulianddecreasedspeedofprocessing
informationalsolimitthepersonsabilitytoassessthepossibleconstraintsandopportunities
withintheenvironment.Thislimitshis/hercopingstrategies.

Aseriousillnessorinjuryinearlylifeoftencausesdamagetocertainbraincells.Theperson
mustrelearnthefunctionsregulatedbythesecells.Latercognitiveimpairmentcanresultfrom
incompleterelearningandtheillnessratherthanfromtheagingprocessalone.

Numerousillnessescanreducecognitivefunctionandcausedisorientationorconfusion.Poor
healthandlowerenergylevelscausethepersontoresistbecominginvolvedinplannedlearning
activitiesandtoscorepoorlyonintellectualtests.Evenmilddiseasenegativelyaffects
intellectualperformance,especiallymemory,adherencetogiventasks,answeringappropriately
andorderedsequenceofthought.Thus,anyillpersonwillshowlessmentalacuity,whichmust
beconsideredwhenplanningandgivingcare.

Rapiddecliningcognitivefunctionmaybeapredictorofdeathifthepersonhaspreviouslybeen
alertandmentallycapable.Studiesindicatethatintellectualfunctionsdeclineintheaged
personprimarilyoneyearbeforenaturaldeath(Murray1980).

THECRISISOFDEATH

IntheMiddleAges,thepersonwasveryawareofnaturalsignsorpremonitionsthathe/shewasdying
andwasactiveindoingtheritualsthatpreparedfordeath.Lovedonesquietlykeptthevigilwith
him/her.Deathwasfamiliarandnear.Itevokednogreatsorrow,aweorfear.Abouttheeighteenth
century,deathbecameromanticizedandbecameintertwinedwithlove.Concernsaboutthedeathof
othersbecameofgreaterconcernthanpersonaldeath.Gradually,deathwasviewedasadisruption.
Sorrowwasopenlyandintenselyexpressed.

Inthetwentiethcentury,deathhasbecomefrightening,tabooandunfamiliar.Althoughdeathis
frequentlypresentedinthemassmediaandmoviesandmanydisastersarepublicized,fewpeoplehave
directcontactwithdeath.Mourninghasbeensuppressed.Thelanguageofourcultureavoidsdeath

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withphraselike;Hepassedon.Hegrewweak.Heissinking.Sheisgone..Humormaybeused
torefertodying,toexpressfearsofdeath,topredictdeathortoconveydoubtsaboutstaff
competence.Medicalcaretechnologyfurtherdepersonalizesanddeniesdeath.Thepersonisno
longerinchargeofhis/herdying,evenifhe/sheareawareofhis/herstatus(Murray1989).Thesenior
haslivedthroughsomeofthisevolution.He/shemayhavehelpedcareforsickanddyingparentsat
homeandisperplexed,perhapsangry,whenhe/sheissenttoanursinghomeorhospital.

Althoughconsiderableliteratureandmediacoveragearedevotedtodeathanddying,peopleintheU.S.
stillseemuncomfortablewiththetopic.Inspiteofincreasedeffortsatprofessionaleducationabout
deathanddying,careofthedyingelderlypopulationstillisneglectedinmanyinstitutions.

Someculturesbelievethatlifeanddeathcanbecontrolledbytheperson.Voodoodeathor
spontaneousdeathsarewelldocumented.Thepersonwaseitheravictimoftheenemyorhe/she
willedhimorherselftodeathwhenhe/shehasbrokenatabooandthenhe/shediesshortly
thereafter.Themedicinemanisimportantinmanyculturestoorganizethecommunitysattitude
towardthedyingperson.Ithasbeenseenthatifsupportiswithdrawn,thepersongivesupandsoon
dies.Ifthemedicinemanconveysthatthepersoniscurable,thecommunitybecomessupportiveand
thepersonsurvives.

Thesituationforourelderlymaynotbetoomuchdifferent.Beinghospitalizedandcutofffromtherest
ofthecommunity,mayhastendeath.ThisissomethingNativeAmericans,Orientals,Chicanosaswellas
theelderlyhaveknownastheyweresubjectedtoimpersonaltreatment.However,sincehospitalsare
attimesnecessary,effortshavebeenmadetocreateawarm,supportiveenvironment.

Premonitionsofdeathareapparentlypresentinmanyseniors,althoughtheymaybereluctanttosayso.
Sometimestheseniorwillpredictwhenhe/shewilldie.Theelderlymayexertmorecontrolovertheir
longevityandtimeofdeaththaniscommonlyrealized.Oftenitappearsthatthepersonwillnotgiveup
lifeuntilhe/shehassaidfarewelltoacertainlovedone.

Longevityisincreasedwhentheolderpersonpossesthefollowingcharacteristics:

Useful,satisfyingrole willingnesstoadjustandchange
Positiveviewoflife lifetimehabitsofmoderation
Assertiveattitude interestinothersandthefuture
Competentphysicalandmentalfunctioning creativeandexpansivethinking

Interestingly,onestudyfoundthatthepatient,whosurvivedlongerthanpredicted,wasangryabouthis
illness,fearfulofdeathanddeterminedtoliveinsteadofbeingresignedtodeath(Benoliel1970).
Attitudesaboutdeathdifferinvariouscultures.Moralityoccursatanearlierageinlower
socioeconomicgroupsandamongracialminoritiesintheUnitedStates.Therefore,deathmaybe
perceiveddifferentlybydifferentgroups.InastudycomparingBlackAmericans,MexicanAmericans
andWhiteAmericans,fearsofdeathwererelatedmoretoagethantoracialgroup.Middleagers

72

expressedmorefearthantheelderly,andwomenweremoreexpressiveoftheirfeelingsthanmen.
However,theydidnotthinkaboutdeathasfrequently.Whiteswerelesspreoccupiedwithdeaththan
theotherminorities.ElderlyMexicanAmericansexpressedtheleastfearofdeath.YoungMexican
Americansexpressedthemost.

IntheUnitedStates,deathisexpectedtocometotheelderly,topeoplenolongerintheworkforce.
Thus,societyoverallisnotconcernedwithdeathunlessitoccurstotheyoungoroccursviolently.Even
ifdeathcomesearly,littledisruptionoccursbecauseworkisorganizedsothatmajorinstitutionsare
relativelyindependentofthepersonswhocarryoutworkroleswithinthem.

Fearofdeathisapparentlymorecommonintheyoungthanintheelderly.However,theelderly
expressfearofdeathwhenacrisisinthesocialenvironmentisdisruptingpriorlifestyleandacceptance.
Forexample,thosewhoaremovedtoorliveinanursinghomearemorefearfulthantheelderlywho
liveinthecommunityandwhoarenotexperiencingrelocation.Theelderlysufferingpsychiatricillness
mayalsoexpressfearofdeath.Theelderlyinastablesituationfeelmorepeaceandequanimityabout
death.

1. MEANINGFDEATH

Totheelderly,deathmayhavemanymeanings:
...afriendwhobringsanendtopainandsuffering
ateacheroftranscendentaltruthsuncomprehendedduringlife
anadventureintotheunknown
reunionwithlovedones
arewardforlifewelllived

Deathmaymeanthegreatdestroyer;thecessationoflifewitheternalnothingness;punishment
andseparation;orawaytoforceotherstogivemoreaffectionthantheywerewillingtogiveinthe
past.Suicidemaybeseenasawaytogaincontroloverdying,joinlovedonesorendanapparently
hopelesssituation.

Thematurepersonrecognizesthatdyinganddeatharephasesoflivingandlife.Thedecreased
energylevel,religiousbeliefsandlossofmostsignificantpeoplealsofacilitateaphilosophical
attitudetowardclosure.Childrenandgrandchildrenalsobestowontheolderpersontheremainder
ofcontinuityoflifeandtangibleevidenceofhisorherongoingcontributiontomankind.Theperson
whohasleftissuesunsettled,dreamsunfulfilled,hopesshatteredorletmeaningfulthingspass
him/herby,issometimesreluctancetodie.Knowingofonesmoralityallowsthepersontostart
preparingearlyforthelastdevelopmentalstagetolivelifeinsteadofpassingthroughit.

2. PREPARATIONFORDEATH
Mostpeopleadmittothinkingaboutdeathatsometime.Usuallythesethoughtsaretriggeredby
externaleventssuchasanaccidentornearaccident,aseriousillnessordeathofsomeoneclose.

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 Yet,someolderpeopledonotmakeplansfordeath,asifplanningwillhastendeath.Theelderly
aremoreconcernedaboutthedyingprocessand:
a. Thepain
b. Beingaburden
c. Lossofbodilyandmentalfunctions
d. Dependenceuponothers
e. Rejection
f. Isolationandseparationfromlovedones
g. Inabilitytotakecareofpersonalbusiness
h. Lossofsocialroles

Themorerelationshipsthatareimportanttothesenior,themoretieshe/shehastoundo.This
causesgrieftobegreater.Mostdonotwishtohavelifeprolongedbymachines.However,
therearetimesthatsuchtreatmentiswarranted.Lifesupportmachinesgiveseniorsandfamily
extratimetopreparefortheirdeath.Someseniorsfeelthebestwaytoavoidprolonged
suffering,dyingandpreparationfordeathistoexpresstheirdesirestofamilyandphysician
throughtheLivingWill.

Deathcanbeplannedindifferentways.Forexample,aprominentProtestanttheologianand
hiswifeputtheiraffairsinorder,saidtheirfarewells.Theywroteanotetotheirchildrenand
grandchildren.Thenoteexplainedthereasonfortheirbehavior.Theywrotethattheirhealth
wasquicklyfailing.Theyrequiredalmostconstantcare.Soontheywouldbetoodependentto
livewithoutdignity.Theydidnotwanttotakeupspaceinaworldwherethereweretoomany
mouthstofeedandtoolittlefood.Theyfeltitwasamisuseofsciencetokeepthemtechnically
alive,sotheycommittedsuicide.

Theythoughtcarefullyandbelievedtheyhadtherighttodecidewhentodie,andthedecision
wasnotturningagainstlifeasthehighestvalue.Theyclearlywerenotactingfromdepression,
despair,painormentalincompetence.Theyriskedcondemnationbecausetheirreligiondoes
notsanctionthis.However,theyfelttheiractionwaslogicalandthiswillbecomemore
acceptableinthefuture.

CharlesLindberghalsoplannedhisdeath,butinadifferentway.Whenheknewhewas
terminallyill,heselectedhisgravesite.ItwasonatropicalislandofMaui.Hethenmadeall
thenecessarylegalarrangements.Eightdaysbeforehisdeath,whenthedoctorstoldhimhe
hadlittletimelefttolive,heflewfromNewYorkCitytoMaui.Then,withhisfamily,physician
andtwonursesspentthelasttwodayslookingattheplacehelovedandreminiscing.He
receivedthenecessarycare,butnomeasurestoprolonglife.Hisdeathwaslikehislife;simple,
wellplanned,considerateandhumble.

MostseniorsdonothavethemeanstofulfilltheirdreamsasLindberghdid.Manyaretakento
institutions.Theyendureavarietyoftests,drugsandprocedures.Theyhaveminimalcontrol

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 overtheirlivingordying.Preoccupationswithsymptoms,painandtherigorsoftreatment
precludequietcontemplation,meaningfulliferevieworsereneacceptanceofdeath.Medical
staffmayresistdeathmorevigorouslythanthepatientandoftendonotcredittheseniorwith
enoughmaturitytounderstandoracceptthefinalityofhis/hercondition.

Althoughafewseniorsmaintaindenial,mostdesireaplanfortheirdemise.Youmaybeof
assistancetothemastheyvalidateideasorneedspecifictaskstobedone.Oryoumayassist
thembylettingthedoctorknowthattheseniorcanaccepthis/hercondition.Thedoctorcan
statethediagnosisandprognosishonestlywithoutconferringhopelessness.Iftheperson
insiststhathe/shedoesnotwanttobetoldanything,his/herrequestshouldbehonored.
Often,thepersonisawareofthetruth,butavoidstalkingaboutit.Preparationfordeathis
moreimportantforsomeelderlythanforothers.Someneedtomakeprovisionsfortheirheirs
andfinalizebusinessandlegalaffairs.

Formanyelderly,aspiritualpreparationfordeathisofgreatimportance.Premonitionof
impendingdeathmaygiveopportunityforlongdeferredselfexaminationandforgainingnew
meaninginlifeanddeath.Areconciliationofconflictsisonesreligiousfaithcanbe
accomplished.Personalhurtscanbeamendedandtenuousrelationshipscanbestrengthened.
Eachdaybecomespreciousandmeaningful.

Peopledieastheylive.Thosewhofoundmeaninginlifeareunafraidofitsend.Ifsuccessinlife
hasbeenmeasuredbymaterialstandards,deathmaybeapproachedwithbitternessand
anguish.Religiousfaithisnotnecessarilyafactor.Agnosticsandatheistmayacceptdeathwith
asmuchtranquilityasareligiousbeliever.

Certaindevelopmentalchangesoccurinthelastyearpriortodeaththatareunrelatedtoage
andillnessandappeartobepredictorsofdeath.Thesecharacteristicsofapproachingdeath
whichareoftenmonitoredbytheillelderlyinclude:

a. Poorerperformanceofvarioustasks
b. Lowerenergylevel
c. Slowerreactiontime
d. Declineincognitivefunctioning
e. Shortenedmemory
f. Decreasedplanningability
g. Reducedemotionalcomplexity
h. Decreasedplanningability
i. Reducedemotionalcomplexity
j. Decreasedabilitytocopewithstress
k. Amorenegativeselfimage
l. Lesscapacityforlearning
m. Lessassertivenessandflexibility

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 n. Increasedintrospection

Theseniorexpressesmoreanxiety,morehopelessness,butfewerexpectationsaboutthe
future.Hefeelsthathis/herbodyisnolongerfunctioningaswellasitdid,evenbeforeovert
signsandspecificsymptomsappear.Thepersonmaysay,IfeellikeImslippingandIdont
thinkIllbeherenextyearatthistime.Theseniormayshowincreasedinterestinhissocial
andmaterialenvironment;itisadisservicetoisolatethesenioratthistime.

3. AWARENESSOFDYING
Peopletodayarebettereducatedgenerallybythemassmediaaboutthemanifestationsofthemain
killers,cardiovasculardiseaseandcancer,thantheywereinthepast.Further,thelegalaspectsof
informedconsentarerigorous.Manyprocedurescannotbeperformedwithoutgivingthesenioran
honestexplanation.Thus,mostpeoplearelikelytoknowintellectuallyeveniftheydonot
emotionallyaccepttheirterminalillness.Yet,somedoctorsandfamiliespersistinwantingtokeep
thediagnosisandprognosisfromthepatient.Theyfeelthattheelderlypersonwillbeunableto
acceptthenews.

Differentstagesthattheterminallyillpatientmayexperienceinclude:

a. CLOSEDAWARENESS
Closedawarenessexistswhenthepersonhasnotbeeninformed.Alsoheorshehasnot
discoveredtheseverityofhis/hercondition.He/shemaynotbeawarebecausehe/sheis
alsonotknowledgeableaboutthesignsofterminalillness.Additional,he/shemaybein
denialandnotawareoftheseverityofthedisease.Maintainingaclosedawarenessis
easierinthehospitalthanathome.Thenurse,ofcourse,maybeplacedinthemiddle,in
suchasituation,foritisdifficulttocommunicateopenlywhenasecretmustbekept.
Familymembersarerobbedofanopportunitytobehonest,sharetheirgriefwiththeloved
oneorplantogetherforthefuture.Thepatienthasnoopportunitytoworkthroughhis/her
doubtsorfearsormakeplansforhis/herlovedones.Nooneeverlearnsoftheresilienceor
maturityofthesenior,whomaybemoreabletocopethananyonerealizes.Keepingthe
patientuninformedisatravestyofcare,inmostcases.Howeversilentthepatientmightbe
abouthis/hercondition,he/shemayhaveapremonitionabouthis/herstatus.Thesenior
watcheshis/hercaretakersandfamilycloselyforcluesabouthimorherself.He/shemay
cometotheconclusionthathe/herisverysickanddyingashe/sheoverhearssnatchesof
conversationorseestearyeyes(Benoliel1970).

Isolationisexperiencedwhenfamilyandfriendsrelatedifferentlytothepatientafterthey
learnthathe/sheisdyingfromaknownterminalillness.Theynolongersharewiththe
patient.Conversationbecomessuperficial,stiltedandlacksspontaneityastheytrytokeep
thepatientfromlearninghis/herdiagnosis.Suspiciousawarenessexistswhentheperson
believeshe/sheisdyingbutsaysnothingtoconfirmhis/heridea.Usuallyhis/her
deterioratingphysicalstatus,otherssilenceortheirbrusqueanswerstohis/herqueries,a

76

 moveclosetothenursesstation,extraattentionfromrelativesrarelyseenorshorterand
fewercontactswiththehealthcareteam,confirmhis/hersuspicions.Theseniorknowsthat
he/sheisdyingbutrealizesthatothersaroundhimdonotknowthatheknows.

Mutualpretenseoccurswhenfamily,patientandstaffenterintoagame.Allrealizethat
thepatientknowshe/sheisdyingandcontinuetopretendotherwise.Thepatientcanplan
his/herremaininglife,buthe/shecannotsharethiswithanyoneclose.Noonecanbe
honest;noonebenefitsfromthepatientsawareness.Eventhepatientcannotdo
anticipatorygrievingorlegalandbusinessplanningverywell.

b. OPENAWARENESS
Openawarenessexistswhenthepatientandfamilyarefullyawareoftheterminalcondition
andcantalkaboutit,althoughthenearnessofdeathmaynotbeestablished.Nowthe
seniorcanreminisceandconductlifereview.He/shecangivetreasuredpossessionstothe
rightperson.He/shecanbeincontrolofhis/hersituationtoagreaterdegreeashe/she
finishesimportantworkandmakesplansforandsaysfarewellstothefamily.He/shelearns
howfamilymembersperceivetheircomingloss;his/herdeath.He/shecansharehis/her
feelingsoflossashe/sheanticipatesdeath.Theanguishisnotreduced,butitcanbefaced
together.

Thestaffwillalsobemoreinvolvedwiththeseniorashe/shetalkstothemabouthis/her
death.Thestaffmayfinditmoredifficulttocareforthepersonwhoknows.Staffcannot
hidebehindclichs.Theyhavetoinvolvesomethingoftheselfandseehim/herasa
person,notathing.Theseniororfamilymayrequestextraprivileges,whichtherulebound
nursefindsdifficulttofulfill.He/shemaywishtodieathome,andthefamilyandstaffmay
worktogethertosetupcareathomeandsecurethehelpofahomehealthagency.The
seniorwhoknows,mayquietlybutfirmly,conveythathe/shewishestobegrantedprivacy
anddignity,bothofwhichmaybedifficulttoobtain.

4. SEQUENCEOFREACTIONSTOAPPROACHINGDEATH
Dr.E.KublerRossdescribesaseriesofreactionsthatthepersonandfamilygothroughasdeath
approaches.

Thesestagesare:
a.Denial
b.Anger
c.Bargaining
d.Depression
e.Acceptance

a. Denial

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 Denialandisolationaretheinitialandnaturalreactionswhentheseniorbecomesill
orlearnsofaterminaldiagnosis:Itcantbetrue;Idontbelieveit.Denialismore
likelyinthepersonwhoistoldtooquicklyorabruptlybythedoctor.Denialmaybe
manifestedbyminimizingorrefusingtoacknowledgehis/herillnessordiagnosisor
thatthediagnosismaychangehis/herlifestyle.

Theseniormaymakeoverlyoptimisticcommentsabouthis/hercondition,refuseto
followdoctorsorders,seekotherdoctorsopinions,tryhomeremediesordelay
hospitaladmission.He/shemayevenbeginunrealisticplansorprojectsthatwillbe
finishedinthefardistantfuture.However,denialdoesnotusuallylastwhenpain,
fatigueorweaknessinterferewithactivity.Astheseniorbecomesawareofhis/her
condition,eitherbecauseoftheextentofhis/hersymptomsorbecausehe/sheis
repeatedlytoldbyothers,he/shemayuseemotionalisolationasadefense.He/she
talksabouthis/herillnessandeventhepossibilityofdeathintellectually,without
emotion,asifthetopicreferredtosomeoneelse.Isolationenablesthepersonto
carryonpracticalactivitiesoflifethatarenecessaryinordertopreparefor
hospitalization,prolongedillnessoreventualdeath.

b. Anger
Angeristhesecondreactionanditoccurswithacknowledgementoftherealityof
theprognosis.Asdenialandisolationdecrease,anger,envyandresentments
towardthelivingarefelt.InAmerica,directexpressionsofangerareunacceptable.
Therefore,angryfeelingsarelikelytobedisplacedontothedoctor,nurse,familyor
eventhefood.Angrydemandsareawaytoavoidneglectandtofeelasenseof
controloveranuncontrollableevent.Thepersonfeelsthathe/shedoesnot
deservetobesick,letalonedie.He/shecanbebitterandhardtomanageas
he/shethinks,Whyme?.

c. Bargaining
Bargaining,thethirdreactionmaybedifficulttoobserveunlessyoucareforthe
elderlypersonregularly.Thepersontriestoentersomekindofagreementwhich
maypostponedeath.He/shetriestobeonhis/herbestbehaviorinordertobe
grantedthespecialwishoflongerlife,preferablewithoutpain.Bargainingmaybe
lifepromoting.Thepersonishopefulandhe/sheexpressesfaithinGodandthe
future.Thebodysphysicaldefensesmaybeenhancedbymentaloremotional
processesyetunknown,andabargainingattitudemayaccountforthenotso
uncommoncasesinwhichthepersonhasaprolonged,unexpectedremissionfrom
adiseaseprocess.Theseniorwhohasanegativeselfconceptorisaloneand
isolated,lacksasenseofhopeandisnotlikelytobargain.He/shefeelsthathe/she
hasnothingtobargainfor.

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 Duringthisstage,theseniorvacillatesbetweendoubtandhope.Sourcesofdoubt
includenewandunexpectedsymptoms.Anyadditionalorunexpectedstressor
relatedtotreatment,financialconcernsorthetemporaryabsenceofthedoctoror
primarynurse.Whenthesourceofstressisrelieved,soisthedoubt.Hopearises
whentheseniorhearsthemedicalpersonnelsayWecanhelpyou.Hopealso
ariseswhentheseniorisencouragedtobeactivelyinvolvedinhis/hertreatment,by
workingwithdoctorsandnursesagainstthedisease,bybeingtreatedataleading
medicalcenter,andbyovertlyhopefulattitudesofthestaff.

d. Depression
Depression,thefourthreactiontohis/hercondition,occurswhenthepersongets
weaker,needsmoretreatmentorpainmedicationandworriesaboutrealistic
mountingmedicalcostsandevenobtainingnecessities.Rolereversalandrelated
problemsaddtothedepression.Theseniorfeelsshameabouthis/hercondition
andguiltaboutbeingaburdenonothers.He/shemayfeelthattheyarebeing
punishedforpastmisdeeds.He/shemaythinkaboutpastlossesandhis/her
presentconditionandhe/sheworriesaboutthefuture.He/shefeelshopeless.
He/shefearsbeingalone,losingindependence,beingdisfigured,havingpainor
losinghis/hersanity.Themilddepressionthatisfrequentlypresentinthesenioris
worsenedwhenhe/sheanticipatesdeath.Theseniormaylaywithhis/herfaceto
thewall;answerslowly,ifatall;speakwithanexpressionlessvoice;talkinshortand
muddledsentences;orstareoutofthewindow(Rogers1976).Preparatory
depressiondiffersfromreactivedepression.He/shenowgrievesfortheimpending
losseshe/shewillendure.Notonlywillhis/herlovedoneslosehim/her,buthe/she
islosingallsignificantrelationshipsandthings.He/shewillnotbeabletodosome
thingsthathe/shewantedtodo.

Thepersonbeginstoseparatehim/herselffromtheworld.He/shereviewsthe
meaningofhis/herlife,triestosharehis/herinsightswithothersandgradually
withdrawsfrominvolvementinlifearoundhim/her.Ifotherscontinuetoconvey
thattheyexpecthim/hertowanttolive,he/shemayfeelmisunderstoodandmore
depression,turmoilandgrief.Thisdepressionisdifficultforfamilyandstaff.
However,he/sheneedstobeallowedtoemotionallypreparefordeath.

Thequalityoflifethatisbeingleftbehindisdefineddifferentlybyeachperson,
dependingupon:
1)Presentlifesituation
2)Amountofpain
3)Familyrelationships
4)Feelingsofdespairanddependency
5)Workabilities
6)Amountofbodymechanics

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 7)Religiousbeliefs
8)Amountofbodymutilation
9)Pastabilitytocopewithstresses
10)Feelingsoflonelinessandisolation
11)Lossoffreedomimposedbymedicalcaresystem
12)Abilitytocarryonusualroutines
12)Senseofmasteryoveroneselfandoneslife

e. Acceptance
Acceptance,thefinalreaction,comeswhenthepersonhastimetopreparefor
death,whenhe/sheisgivenhelpinworkingthroughpreviousreactionsandwhen
he/sheremainsalertenoughtoemotionallyresolvehis/herdeath.Nowhe/sheis
resignedtohis/herfate.He/sheiswithdrawn,neitherangry,depressed,envious
norresentfuloftheliving.Thepersonisemotionallyandsociallybankrupt.Nothing
ofobviousimportancecanbeaddedtohis/herlifeandnothingcanberegained.
Apathyratherthanserenityoracceptancemaybeseen.

Theseniorcannotorwillnotfurtheraccommodatetotheindignitiesofhis/herdiseases.
He/shehaslivedhis/herlifeanddoesnotwishtorelieveit.He/shesayshis/hergoodbyes.Only
theseniorwhocontinuestoaddtothespiritualdimensionsofhis/herlifewillbeabletousethis
timeforgrowthemotionallyandspirituallyandfeelthathe/sheisaddingsomethingto
him/herselfashe/sheisdying.He/shemayfeelandinnerpeaceandselfpossession.He/she
liveswiththecertaintyofalimitedfuture.He/sheplanshis/herinheritanceandassignshis/her
treasurestoothers.

Unlesshe/sheisunconscious,theseniorwhoisdyingcontinuestofeel,thinkandrespondtothe
presentandlimitedfuture,tohis/herillnessandtothosearoundhim/her.He/shedoesnotjust
liepassivelyandawaitdeath.He/shemaystrivetocontrolandmanipulateothers;toprevent
theirleavinghim/herorwithdrawingtheirlove.He/shemaypretendtoavoidfeelingsofloss
anddespair.

Thepersonmaynotproceedtoacceptance.He/shemayrefusetoadmithe/sheisdying.
He/shemayshowanger,bitternessandselfpity.He/shemayretaliateagainstothers,demand,
clingorberatehim/herself.

Thepersonwhoisdyingoftenfluctuatesbetweenavoidance,denial,anxioushope,rejection,
uneasyresignationandcalmacceptance.Thepersontriestomaintaintieswiththoseclosestto
him/herwhilehe/shewrestleswithimpendingextinction.

Asahealthprofessional,youmustexaminepersonalattitudesandvaluesaboutlifeanddeath.
Youmustbecommittedtohelpingtheterminallyillpersonliveascomfortablyandwithasmuch
meaningaspossibleuntilhe/shedies.Someauthorsfeelthattheelderlyandthechronicallyor

80

 terminallyillaretakingspace,food,oxygenandmoneythatcouldbeusedfortechnological
advancestohelpthosewhoarewelloratleastcurable.

Itwouldbeeasytoassumethatwearehelpingthechronicallyorterminallyillandthedying
personbyendingtheirmisery;puttingthemtosleep;withtheirconsent,ofcourse.Eachofus
mustworkvigorouslytopreventsuchanethicfromtakinghold.

Dosobyclearlyknowinginsideyourselfthateverypersonisvaluable,includingthedying
person.Sufferingcanbecomforted,althoughavegetativestateneednotbeartificially
prolonged.Thepatientcanrefusetreatment.Knowclearlythatunlessyouworktohumanize
careofthechronicallyorterminallyillperson,youcanpredictwhatyouwillreceivewhenyou
areinthesituationyourself.

Forselfishreasons,ifnotforaltruisticreason,itisessentialtoassertyourvalues,knowledge
andskillsonthesideofthosemostvulnerableandleastabletospeakforthemselves.Alook
intoyourself,andincreaseawarenessaboutyourvalues,isthefirststepintherightdirection.3

Yet,modernmethodsofresuscitationthatareusedwhenlivescanbesavedareoutofplace
whendiseaseoraccidenthasnearlyendedtheseniorslife.Thisisespeciallytrueif
resuscitationrenewshis/hersufferingandhe/sheispreparedforanddesirousofdeath.The
dyingoughttobeallowedtodepartinpeace,andafterdeath,thebodyshouldnotbe
immediatelydisturbed.Disturbanceofthedeadbodymayhavenoeffectonthedeceased,but
itrobsbereavedbystandersoftheirpeaceandconsolidation.

3
Opinionsexpressedinthiscoursearethoseoftheauthor.Itisrecognizedthattherearevaryingopinionssurroundingthetopicsof
treatingtheterminallyillpatient.

81


CHAPTER VI


DRUGTHERAPIES
FORTHE
ELDERLYCLIENT

82

 DRUGTHERAPYINTHEELDERLY

PHYSIOLOGICCHANGESAFFECTINGDRUGACTION

Asapersonages,gradualchangesoccurinthehumanphysiology.Agerelatedchangesmayalter
therapeuticandtoxiceffectsofdrugs.

1. BODYCOMPOSITION
Proportionsoffat,leantissueandwaterinthebodychangewithage.Totalbodymassandlean
bodymasstendtodecrease.Theproportionofbodyfattendstoincrease.Varyingfromperson
toperson,thesechangesinbodycompositionaffecttherelationshipbetweenadrugs
concentrationandsolubilityinthebody.Forexample,awatersolubledrug,suchasgentamicin,
isnotdistributedtofat.Sincethereisrelativelylessleantissueinanelderlyperson,moredrug
remainsintheblood,andtoxiclevelscanresult.Likewise,pentobarbital,whichisdistributedto
fat,mayproducelowerlevels.

2. GASTROINTESTINALFUNCTION
Intheelderly,decreasesingastricacidsecretionandgastrointestinalmotility,slowthe
emptyingofstomachcontentsandmovementofintestinalcontentsthroughtheentiretract.
Furthermore,althoughinconclusive,researchshowstheelderlymayhavemoredifficulty
absorbingmedications.Thisisaparticularlysignificantproblemwithdrugshavinganarrow
therapeuticrange,suchasdigoxin,inwhichanychangeinabsorptioncanbecrucial.

3. HEPATICFUNCTION
Theliversabilitytometabolizecertaindrugsdecreaseswithage.Thisisprobablydueto
diminishedbloodflowtotheliver.Thisresultsfromtheagerelateddecreaseincardiacoutput.
Whenanelderlypatienttakescertainsleepmedications,suchassecobarbital,his/herlivers
reducedabilitytometabolizethedrug,mayproduceahangovereffectduetocentralnervous
systemdepression.Eliminationofthesemedicationsishighlydependentontheliver.

Decreasedhepaticfunctionmaycause:
a.Moreintensedrugeffectsduetohigherbloodlevels
b.Longerlastingdrugeffectsdueto:
Prolongedbloodconcentrations
c.Greaterincidenceofdrugtoxicity

4. RENALFUNCTION
Mostelderlypersonsrenalfunctionisusuallysufficienttoeliminateexcessbodyfluidand
waste.However,his/herabilitytoeliminatesomemedicationsmaybereducedby50%or
more.

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 Manymedicationscommonlyusedbytheelderly,suchasdigoxin,areexcretedprimarily
throughthekidneys.Ifthekidneysabilitytoexcretethedrugisdecreased,highblood
concentrationsmayresult.Digoxintoxicity,therefore,isrelativelycommon.

Drugdosagescanbemodifiedtocompensateforagerelateddecreasesinrenalfunction.Aided
bylaboratorytests,suchasBUNandserumcreatinine,clinicalpharmacistsanddoctorscan
adjustmedicationdosagestoprovidetheexpectedtherapeuticbenefitswithouttheriskof
toxicity.Patientsshouldbeobservedforsignsoftoxicity.Apatienttakingdigoxin,forexample,
mayexperienceanorexia,nauseaandvomiting.

5. ADVERSEDRUGREACTIONS
Ascomparedwithyoungerpeople,theelderlyreportedlyexperiencetwiceasmanyadverse
drugreactions.Thisfactmightbeduetogreaterdrugconsumption,poorcomplianceand
physiologicchanges.

Signsandsymptomsofadversedrugreactions;confusion,weaknessandlethargy;areoften
mistakenlyattributedtosenilityordisease.Iftheadversereactionisntidentified,thepatient
maycontinuetoreceivethedrug.Furthermore,he/shemayreceiveunnecessaryadditional
medicationstotreatcomplicationscausedbytheoriginalmedication.Althoughanymedication
cancauseadversereactions,mostoftheseriousreactionsintheelderlyarecausedbya
relativelyfewmedications:diuretics,digoxin,corticosteroids,sleepmedicationsand
nonprescriptiondrugs.Patientswhotakethesedrugsshouldbecarefullyobservedfor
toxicities.

a. Diuretictoxicity
Becausetotalbodywaterdecreaseswithage,normaldosesofpotassiumwastingdiuretics,
suchashydrochlorothiazideandfurosemide,mayresultinfluidlossandevendehydration
intheelderlypatient.Thesediureticsmaydepleteserumpotassium,causingweaknessin
thepatient;andtheymayraiseblooduricacidandglucoselevels,complicatingpreexisting
goutanddiabetesmellitus.

b. Digoxintoxicity
Asthebodysrenalfunctionandrateofexcretiondecline,digoxinconcentrationsinthe
bloodmaybuildtotoxiclevels,causingnausea,vomiting,diarrheaandmostserious,cardiac
arrhythmias.Severetoxicitymaybepreventedbyobservingthepatientforearlysignssuch
asappetiteloss,confusionordepression.

c. Corticosteroidtoxicity
Elderlypatientsoncorticosteroidsmayexperienceshorttermeffectsincludingfluid
retentionandpsychologicalmanifestationsrangingfrommildeuphoriatoacutepsychotic
reactions.Longtermtoxiceffects,suchasosteoporosis,canbeespeciallysevereinelderly
patientswhohavebeentakingprednisoneorrelatedcompoundsformonthsorevenyears.

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 Topreventserioustoxicity,especiallyobserveforsubtlechangesinappearance,mood,
mobility,aswellasforsignsofimpairedhealingandfluidandelectrolytedisturbances.

d. Sleepmedicationtoxicity
Insomecases,sedativesorsleepingaids,suchasflurazepam,causeexcessivesedationor
residualdrowsiness.

e. Nonprescriptiondrugtoxicity
Whenaspirinandaspirincontaininganalgesicsareusedinmoderation,toxicityisminimal,
butprolongedusemaycausegastrointestinalirritationandgradualbloodlossresultingin
severeanemia.Althoughanemiafromchronicaspirinconsumptioncanaffectallage
groups,theelderlyaremostvulnerabletoitbecauseoftheiralreadyreducedironstores.

Laxativesmaycausediarrheainelderlypatientswhoareextremelysensitivetodrugssuch
asbisacodyl.Chronicoraluseofmineraloilasalubricatinglaxativemayresultinlipid
pneumoniaduetoaspirationofsmallresidualoildropletsinthepatientsmouth.

f. Patientnoncompliance
Approximatelyonethirdoftheelderlyfailtocomplywiththeirprescribeddosesortofollow
thecorrectschedule.Theymaytakemedicationsprescribedforpreviousdisorders,
discontinuemedicationsprematurelyorusePRNmedicationsindiscriminately.

Themedicationregimenshouldbereviewedwithhim/her.Thepatientmustclearly
understandthedoseandthetimeandfrequencyofdoses.Also,he/sheshouldknowhow
totakeeachmedication,thatis,withfoodorwaterorbyitself.

Thepatientshouldbegivenwhateverhelpisnecessarytoavoiddrugtherapyproblems,and
referredtoaphysicianorpharmacistiffurtherinformationisneeded.

REFERENCES
______________,AgingandBehavior,NewYork:SpringerPublishingCo,Inc.,1973.

Beland,Irene,andPassos,Joyce,ClinicalNursing:PathophysiologicalandPsychosocial
Approaches,NewYork:MacMillanPublishingCompany,Inc.,1975.

Botwinick,Jack,CognitiveProcessesinMaturityandOldAge,NewYork:SpringerPublishing
Company,Inc.,1967.

BowermFay,TheProcessofPlanningNursingCare:ATheoreticalModel,St.Louis:TheC.V.
MosbyCompany,1992.

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 Carney,Beatrice,UnderstandingClinicalDepressionintheElderly,Gerontology,Spring
1991,pp67.

Cowley,M.,NoCure,JustCare,AmerJournalofNursing,74:No.11(1974),21012.

Curtis,J.,Rothbert,M.,Christian,B.,APracticalEvaluationofNursingCareasPartofthe
NursingProcess,NursingDigest,3:No.3(1975),2021.

Goldman,R.,TheDeclineinOrganFunctionwithAging,inClinicalGeriatrics,ed.,Isadore
Rossman,Philadelphia:J.B.LippincottCompany,1971.

______________________,HealthAssessmentHandbook,Nursing93Books,Springhouse
Corporation,Springhouse,PA.,1993.

KublerRoss,E.,OnDeathandDying,London:CollierMacMillan,Ltd.,1969.

McCain,R.F.,NursingbyAssessmentNotIntuition,AmericanJournalofNursing,65:No.
4(1965),8284.

Murray,R.B.,Huelskoetter,M.W.,ODriscoll,D.R.,TheNursingProcessinLaterMaturity,
PrenticeHall,Inc.,EnglewoodCliffs,Newjersey,1980.

Murray,R.,Zetner,J.,NursingConceptsforHealthPromotion,2nded.,EnglewoodCliffs,NJ,
PrenticeHall,Inc.,1979.

_____________,ThePhysiologyofAging,ScientAmer,206:(1962),100110.

Pollak,Otto,HumanBehaviorandtheHelpingProfessions,NewYork:Spectrum
Publications,Inc.,1976.

ProfessionalGuidetoDrugs,IntermedCommunications,Inc.,Springhouse,PA,1993.

Rogers,Carl,ClientCenteredTherapy,Boston:HoughtonMiffinCompany,1976.

Rotrock,L.,Miller,L.,ActiveandAlert:LearningExperiencesforOlderAdults,JeffersonCity,
MO,MissouriOfficeofAging,1976.

Stosky,B.,TheElderlyPatient,NewYork:GruneandStratton,Inc.,1968.

Tom,Cheryl,NursingAssessmentofBiologicalRhythms,NursingClinicsofNorthAmerica,
11:No.4,(1976),62130.

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 Wyzant,W.,Dying,ButNotAlone,AmerJofNursing,67:No.3,(1967),54777.

GERIATRICNURSINGPRINCIPLESTEST

Eachquestionhasonlyonecorrectanswer.Logbackontoourwebsitetoinputyourtestanswers.
Alwayskeepacopyofyouranswersforfuturereference.

1. Themajorreasonforthelengtheninglifespantodayis:
a. Betternutrition
b. Bettermedicalcare
c. Betteruseofpreventionmeasures
d. Allofthese
2. Themedicalandnursingprofessionshave__________________toplanforandimplement
healthcaretomeettheuniqueneedsoftheelderly.
a. Movequickly
b. Ignoredtheneed
c. Notbeenquick
d. Passedtheamendmentsnecessary
3. Howimportantareyou,thenursetoyourelderlypatients?
a. Very
b. Somewhat
c. Alittle
d. Notatall
4. Latermaturityreferstothelastdevelopmentalstageoflife,usuallybeginningafterretirement
atabouttheagesof____to____.
a. 6064
b. 7580
c. 6570
d. 8085
5. Agedis:thatpointinthelifespanofapersonwhenchangesofaging
a. Associatedwithdecliningfunction
b. Makedependencyonothersnecessary
c. Markedlyinterferewithfunctioning
d. Makenodifferenceinlifespan
6. Nootherdevelopmentalera(theelderly)issorigidly_____________________.
a. Biasedinattitude
b. Victorian
c. Setintheirways
d. Stereotyped
7. Inordertoperceivetheseniorasauniqueperson,youmustconsider:
a. Yourpersonaldefinitionsaboutaging
b. Yourvaluesaboutaging

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 c. Yourattitudesaboutaging
d. Yourfeelingsaboutoldage
e. Allofthese
8. Firstlevelassessmentisdoneon______________withtheelderlypersontodeterminethe
perceivedhealththreat.
a. Initialcontact
b. Secondvisit
c. Admission
d. Discharge
9. Anursinghistoryformorassessmenttoolis____________informationobtainedin1stand2nd
levelassessment.
a. Neverusedfor
b. Anorganizedmeansofrecording
c. Acomprehensiveviewof
d. Allofthese
10. Thenursinghistoryshouldincludethefollowinginformation:
a. Developmentalstatusandlevelofbehavior
b. Previousexperiencewithillness
c. Educationallevelandintellectualcapacity
d. Allofthese
11. Adheringtoaseniorsestablishedpatternpromotestheirwellnessandtheirfeelingof:
a. Beingcaredfor
b. Security
c. Wellbeing
d. Uniqueness
12. Obtainingalengthyassessmentorhistoryisanecessaryactivityfor:
a. Makinganursingdiagnosis
b. Individualizingcare
c. Improvingcommunicationskills
d. Makingrealisticdischargeplans
13. Whentakinganursinghistory,askingabarrageofquestionswilltendto________theseniors
expression.
a. Enhance
b. Minimize
c. Expand
d. Stifle
14. Themoreskillfulyouareacommunicator,thebetteryourassessmentdatawillbeasthebasis
for:
a. Nursingcareplans
b. Continuedcare
c. Nursingdiagnosis
d. Behavioralobjectives

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 15. Nursingdiagnoses__________labelmedicalentities.
a. Do
b. Donot
c. Never
d. Always
16. Nursingdiagnosesrefertoconditionsthatcanbehelpedbynursing__________.
a. Action
b. Care
c. Assessment
d. Intervention
17. Nursingdiagnosesthatmaybeapplicabletothepsychologicalandphysicalstatusoftheelderly,
include:
a. Impairedmobility
b. Anxiety,confusion
c. Negativeselfimage
d. Impairedsensoryprocess
e. Allofthese
18. Statementsaboutapredictedordesiredpatientoutcomeformulatedwiththepersonorfamily
arecalled:
a. Longtermgoal
b. Shorttermgoal
c. Patientcaregoal
d. Nursingdiagnoses
19. Prioritiesofpatientcaregoalsareaffectedbywhichofthefollowing:
a. Potentialforrecoveryorsusceptibilitytorelapse
b. Canbeaccomplishedinashortperiodoftime
c. Outcomecanbepredictedwithcertainty
d. Thedemiseofthepatient
20. Thewrittennursingcareplanincludethe:
a. Patientsneeds,problems
b. Prioritiesofcare
c. Patientcaregoals
d. Nursingorders
e. Allofthese
21. Thepurposeofthenursingcareplanincludes;
a. Tocommunicateinformationaboutthepersonorfamily
b. Toprovideindividualizedandcomprehensivecare
c. Toprovidecoordinationandcontinuityofcare
d. Tofacilitateongoingandaccurateevaluationofcare
e. Allofthese
22. Nursinginterventionreferstoalloftheactionsthatthenurseengagesin,aswellasthe
approachusedtopromotethepatients________________.

89

 a. Holism
b. Wellbeing
c. Death
d. Marriage
23. Nursinginterventionswiththeelderlypersonorfamilyinclude:
a. Encouragingtheseniortouseenergysavingdevices
b. Maintainingcommunicationwiththesenior
c. Givingwellnesscare
d. Notenablingtheseniortogivehisorherownhygiene
e. aandb
f. candd
24. theelderlypersonmayhavemanyneedswhichneedtobemet,suchas:
a. Physicalneeds
b. Socialneeds
c. Emotionalneeds
d. a,b
e. a,b,c
25. Bowerclassifiesinterventionintothreeactions:supportive,generativeand_______.
a. Helping
b. Collaborative
c. Protective
d. Encouraging
26. Supportivenursingactionsprovide:
a. Comfort
b. Restoration
c. Treatment
d. aandb
e. a,b,c
27. Evaluationofnursingcareisdirectlyrelatedto:
a. Results
b. Effect
c. Accountability
d. Outcome
28. Whenapproachinganelderlypatientforaninterview,whenusuallyistheoptionaltimetotalk
tohim/her?
a. Afterlunch
b. Lateintheday
c. Afterexercise
d. Earlyintheday
29. ____________isthekeytocommunicatingwiththeelderly.
a. Patronizingbehavior
b. Patience

90

 c. Attitude
d. Understanding
30. Ageriatricpatientspasthistoryislikelytobe________________.
a. Minimal
b. Extensive
c. Largerthanlife
d. Voluminous
31. Duringreviewofthefemalereproductivesystem,includequestionsabout:
a. Thyroidreplacementtherapy
b. Menopause
c. Testosteronetherapy
32. Themostcommonpsychogenicproblemsfoundinelderlypatientsis:
a. Anxiety
b. Depression
c. Paranoia
d. Confusion
33. Intheelderly,osteoporosismostcommonlyoccursafterage________.
a. 60
b. 75
c. 80
d. 50
34. Characteristicsofbeingahelpingpersoninclude:
a. Secure
b. Positive
c. Strong
d. Allofthese
35. Theelderlypersoncannotsurvive,emotionallyorphysically,unlesssomeone:
a. Cares
b. Reachesout
c. Loves
d. Neglects

91