NURSING CARE OF THE OLDER ADULT IN Nursing goals/outcomes identification
CHRONIC ILLNESS • The nursing goals for older individuals with
NURSING PROCESS FOR DISTURBANCE IN
SENSORY PERCEPTION
Assessment / Data Collection
• Has the person mentioned any changes in
the taste or smell of food?
• Can the person detect whether something is
cold or warm? Smooth or rough?
• Does the person have known vision
problems (e.g., glaucoma, macular
degeneration, cataracts, refrac tive errors)?
• Does the person see small details or
shadows?
• Does the person frequently walk into or trip
over objects?
• Can the person read? If not, why not? If yes,
can he or she read newsprint or only
largeprint headlines
• How close does the person sit to the
television?
• Does the person wear eyeglasses? If yes,
are they single lens, bifocal, or trifocal?
• When was the last vision examination?
• Does the person respond when people
speak to him or her at normal volumes?
• Can the person hear a whisper from
someone behind or to the side of him or her
who cannot be seen?
• Does the person turn the volume of the
television or radio to a very loud level?
• Does the person turn his or her head to
hear? Wear a hearing aid?
• Does the person respond appropriately or
inappropriately to questions?
• Can the person follow directions?
Nursing Diagnoses
• Risk for Injury related to altered sensory
perception
• Impaired Verbal Communication related to
disturbance in sensory input
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disturbances in sensory perception are to
(1) remain free from injury; (2)
demonstrate improved ability to detect
changes in the environment; (3) interact
appropriately with the environment; and (4)
demonstrate the ability to compensate for
deficits by using prosthetic devices and
alternative senses.
Nursing interventions/implementation
• Ensure that all caregivers are aware of the
person’s sensory problems
• Make appropriate sensory contact before
beginning care.
• Determine the best methods for
communicating with older adults.
• Modify the environment to reduce risks.
hemanopsia-portion of the visual field is lost
• Verify that prostheses such as eyeglasses
and hearing aids are functional.
The following interventions should take place in the
home:
1. Modify the home environment to
compensate for sensory changes.
2. Assist sensorially impaired people in
developing techniques or acquiring devices
that will help compensate for losses.
• Hearing Impaired People
• Visually Impaired Persons
Individual sensory impairments are common:
hearing loss (33%) and vision impairment (18%)age
70 and older deficits in smell (24%) taste (up to
61%) common in adults 70 and older
Effects of sensory impairment in elderly
adults:
• Visual, hearing and olfactory impairment
They difficulty adjusting to their sensory loss.
Non-correctable visual impairment typically results
from the major age-related eye diseases (cataract,
and glaucoma).
Sensory loss in elderly:
Loss of touch. As a person ages, reduced or changed
sensations result.
This may be an effect of decreased blood flow to the
nerve endings or to the spinal cord or brain.
It can be affected by brain surgery or nerve damage
from chronic disease such as diabetes.
Changes in sensory function occur due to
aging because:
• DECLINE IN THEIR FIVE SENSES. while the
sense of smell, taste and touch all change
with age,
• noticeable changes affect our vision and
hearing.
• senses change, elderly find it difficult to
socialize and participate in activities.
In terms of social and mental well-being, vision
loss and hearing loss have each been shown to be
associated with
1. depression,
2. social isolation,
3. anxiety
4. paranoia, and
5. decreased self-esteem.
VISION
Common vision problems of elderly:
The risk of low vision (ie, where some usable vision
remains) and blindness increases significantly with
age, those over the age of 65.2
The most common age-related eye diseases include
the following:
• Glaucoma -peripheral vision loss;
• Age-related macular degeneration - leads to
central vision loss;
• Diabetic retinopathy -spotty field of vision;
• Cataracts -lead to blurring, clouding of
images, sensitivity to light
• Dry eye -creates insufficient tear production,
making vision-related activities more
difficult.
Effects of Visual problem with Elderly:
• Increased risk of falls and fractures, leading
to hospital or nursing home placement,
increased disability, and premature death
• Increased risk of depression
• Increased difficulty identifying medications,
which can lead to medication-related
adverse events
• Declines in activities of daily living
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Nursing Management for Elderly client with
Visual impairment:
Approach and Attitude:
Always treat a blind person normally- speak first and
introduce yourself. Shake hands but only if a hand is
offered. It is also politeness to look at him/her during
conversation and adopt the same level of position -
sit or stand
Care Intervention
• Sleep pattern control
• Mobility therapy
• Compliance with diet
• Infection control
• Alcohol abuse control
• Positioning therapy
• Energy conservation
HEARING
Common hearing problems of elderly:
• Hearing loss occurs to 80% of people over
of 85 Common sensory deficit
• Lead to severe social and health-related
problems.
• It's problematic in the elderly with hearing
loss - impairs the exchange of information,
thus significantly impacting everyday life
o Loneliness
o isolation
o dependence
o frustration
o communication disorders
When working with older adults, it's good practice
o Tinnitus (ringing in the ears)
o hearing loss (bilateral or unilateral)
o dizziness
o incoordination in movements
o unsteadiness of gait
o oscillating or bouncing vision (vertigo).
Signs of Hearing Loss:
Some people have a hearing problem and don’t
realize it. You should see your doctor if you:
• Have trouble hearing over the telephone
• Find it hard to follow conversations when
two or more people are talking
• Often ask people to repeat what they are
saying
 • Need to turn up the TV volume so loud that
others complain
• Have a problem hearing because of
background noise
• Think that others seem to mumble
• Can’t understand when women and children
speak to you
2 Categories of hearing loss:
1. Sensorineural hearing loss occurs when
there is damage to the inner ear or the
auditory nerve. This type of hearing loss is
usually permanent.
2. Conductive hearing loss occurs when sound
waves cannot reach the inner ear. The cause
may be earwax buildup, fluid, or a punctured
eardrum. Medical treatment or surgery can
usually restore conductive hearing loss.
Common disorders of hearing among elderly
patient:
• Sudden Hearing Loss. Sudden sensorineural
hearing loss, or sudden deafness, is a rapid
loss of hearing. It can happen to a person
all at once or over a period of up to 3 days.
It should be considered a medical
emergency. If you or someone you know
experiences sudden sensorineural hearing
loss, visit a doctor immediately.
• Age-Related Hearing Loss (Presbycusis).
Presbycusis, or age-related hearing loss,
comes on gradually as a person gets older.
It seems to run in families and may occur
because of changes in the inner ear and
auditory nerve. Presbycusis may make it hard
for a person to tolerate loud sounds or to
hear what others are saying.
• Ringing in the Ears (Tinnitus). Tinnitus is
also common in older people. It is typically
described as ringing in the ears, but it also
can sound like roaring, clicking, hissing, or
buzzing. It can come and go. It might be
heard in one or both ears, and it may be loud
or soft. Tinnitus is sometimes the first sign of
hearing loss in older adults.
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Communicating with People with Hearing
Loss:
1. Face the hearing-impaired person directly,
on the same level and in good light
whenever possible
2. Do not talk from another room
3. Speak clearly, slowly, distinctly, but naturally,
without shouting or exaggerating mouth
movements
4. Say the person's name before beginning a
conversation
5. Get Their Attention. Respectfully get the
senior's attention before speaking
6. Reduce Background Noise
7. Speak One at a Time
8. Speak Clearly and Loudly
9. Repeat Yourself
10. Rephrase Your Question or Statement
11.Appearances and Visual Cues Matter
12.Be Understanding
NURSING PROCESS FOR CHRONIC
CONFUSION
Confusion is defined as a mental state
characterized by disorientation regarding time, place,
or person that leads to bewilderment, perplexity, lack
of orderly thought, and the inability to choose or act
decisively and to perform activities of daily living.
NANDA International identifies the following nursing
diagnoses that relate to confusion: acute confusion,
chronic confusion, ineffective impulse control, and
impaired memory (NANDA International, 2014).
Acute confusion, often called delirium, is
characterized by disturbances in cognition, attention,
memory, and perception.
This type of confusion is usually caused by a
physiologic process that affects the autonomic
nervous system.
Conditions that can cause delirium include
uncontrolled pain, infection, metabolic distur- bances,
vitamin deficiencies, uremia, hypoxia, hypercalcemia,
endocrine imbalance, myocardial infarction,
constipation, drug toxicity, and drug withdrawal
Acute delirium has a sudden onset of hours to days.
It is characterized by rapid mood swings,
disorganized sleep cycles, changes in psychomotor
activity (hypoactivity, hyperactivity, or both), tremors
or spasmodic activity, rapid speech patterns, loss of
attention, and a wide range of cognitive changes

DEMENTIA:
• Dementia is a slow, insidious process that
results in progressive loss of cognitive
function.
• Dementia is characterized by changes in
memory, judgment, language, mathematic
calculation, abstract reasoning, and
problem- solving ability; impulsive behavior;
stupor; confusion; and disorientation.
• Changes related to dementia are
progressive and irre- versible.
• In the early stages, many cases of dementia
are mistakenly considered a part of normal
aging, which can result in delayed diagnosis
and treatment.
Common behaviors seen with advanced
dementia include:
• wandering,
• excessively emotional reactions
(catastrophic reactions),
• combative behaviors,
• suspiciousness, and hallucinations or
delusions.
• These agitated behaviors, which are often
worse late in the day, are referred to as the
sundown syndrome or sundowning.
• Affected persons often do not recognize
even their closest family members and
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friends. These abnormal behaviors are
frightening to the family and anyone who
cares about the affected individual.
• Alzheimer disease
• Vascular dementia
• Dementia with Lewy bodies (DLB)
• Mixed dementia
• Parkinson disease dementia
• Frontotemporal dementia
• Creutzfeldt-Jakob disease
• Normal pressure hydrocephalus
• Huntington disease
• Wernicke-Korsakoff syndrome
Types of Dementia
Signs of dementia can vary greatly. Examples
include:
• Problems with short-term memory.
• Keeping track of a purse or wallet.
• Paying bills.
• Planning and preparing meals.
• Remembering appointments.
• Traveling out of the neighborhood.
Diagnosis of dementia
• There is no one test to determine if
someone has dementia.
• Doctors diagnose Alzheimer's and other
types of dementia based on a careful
medical history, a physical examination,
laboratory tests, and the characteristic
changes in thinking, day-to-day function and
behavior associated with each type.
• Doctors can determine that a person has
dementia with a high level of certainty.
Dementia treatment and care
• Treatment of dementia depends on its
cause. In the case of most progressive
dementias, including Alzheimer's disease,
there is no cure, but one treatment —
 aducanumab (Aduhelm™) — is the first
therapy to demonstrate that removing
amyloid, one of the hallmarks of Alzheimer’s
disease, from the brain is reasonablylikely to
reduce cognitive and functional decline in
people living with early Alzheimer’s.
• Others can temporarily slow the worsening
of dementia symptoms and improve quality
of life for those living with Alzheimer's and
their caregivers.
• The same medications used to treat
Alzheimer's are among the drugs
sometimes prescribed to help with
symptoms of other types of dementias.
• Non-drug therapies can also alleviate some
symptoms of dementia.
Differences between Delirium and Dementia
basic body functions such as elimination is
also lost.
• People with Alzheimer disease suffer
personality changes. They lose the ability to
control moods and emotions, leading to
unpredictable and often inappropriate
behavior. Unusual behaviors include
wandering, pacing, hiding things, swearing,
disturbed sleep patterns, and repetitive
actions.
• There is no known cure for Alzheimer
disease. A variety of medications are being
tested for use with this disease, with varying
degrees of success.

ALZHEIMER’S DISEASE DELIRIUM DEMENTIA

• Alzheimer disease is not a normal part of • Rapid onset: hours • Slower onset:
aging. It is a progressive, degenerative, to days months to years
irreversible form of dementia. • Reduced level of • No change in level of
• The disease was first identified in 1906 by consciousness consciousness
Alois Alzheimer, a German neurologist. • Variable course over (initially)
• Most cases of Alzheimer disease occur in 24 hours • Stable over 24 hours
people older than 65 years of age, but it can • Increased or • Impaired memory
occur as early as 30 years of age. decreased with loss of abstract
• Alzheimer disease affects both men and psychomotor activity thinking, judgment,
women of all religions, races, and • Disturbed language skills
socioeconomic backgrounds. sleep/wake patterns (aphasia), motor
• Disorientation and skills (apraxia), and
• The cause of the disease remains unknown,
perceptual ability to recognize
but genetic, chemical, viral, and
disturbances, familiar people or
environmental factors are suspected. Family possible visual and objects (agnosia)
history and the presence of the auditory
apolipoprotein E gene appear to indicate an hallucinations
increased risk for development of the • Memory impairment
disease. • Decreased attention
• Alzheimer disease causes gradual changes span with
such as plaques and tangles in the nerve disorganized
cells of the brain that can be detected on thinking
autopsy. • Generally reversible if • Generally not
• Neurologic changes result in a loss of the underlying problem reversible
ability to process information normally. is identified and
treated; may recur
• The first signs of Alzheimer disease are
with acute illness
subtle changes in behavior. The disease • Designed to maintain
• Designed to treat
affects each individual differently; the type underlying or maximize level of
and severity of symptoms, as well as the pathologic condition function physiologic
order of their appearance, differ from person and maintain integrity
to person. • Includes • Administration of
• People suffering from Alzheimer disease lose administration of medications
the ability to think, remember, understand, fluids, nutrition, (cholinesterase
and make decisions. Consequently, they are oxygen, antianxiety inhibitors); ensure
often unable to perform even the most basic medications and so that fluid and
activities of daily living. The ability to control on nutrition are
maintained

5
 • Designed to control • Includes environment • Structure the environment to minimize
environmental modification, disruption; avoid sudden changes of room or
stressors, to protect activity-based environment.
safety, and to therapies, and • Develop a plan to deal with “acting out”
promote comfort communication behaviors
strategies • Use effective communication skills.
• Consult with family and the multidisciplinary
team.

The following interventions should take place in the

home:

• Help the family accept the diagnosis.

• Help the family adjust to the demands of
providing care for a cognitively impaired
older person.
Nursing goals/outcomes identification • Provide emotional support and help the
family identify coping strategies.
The nursing goals for older individuals with chronic • Identify community resources.
confusion are to: • Help families make arrangements for
institutional placement, if necessary.
1. remain free from injury;
• Encourage families to plan for end-of-life
2. assist in activities of daily living to the highest
decisions.
level possible; and
• Use any appropriate interventions that are
3. seek assistance when needed.
used in the institutional setting
Nursing interventions/implementation
Common causes of Chronic Confusion
• Assess behavior on admission and at regular includes:
intervals.
• Infection – urinary tract infections (UTIs) are
• Provide assistive sensory devices.
a common cause in elderly people or people
• Orient the person to person, place, and time,
with dementia.
and provide any other important situational
• Stroke
informa- tion, but do not force the issue,
• Low blood sugar level in people with
because it can lead to agitation.
diabetes
• Orient the person to person, place, and time,
• Head injury
and provide any other important situational
informa- tion, but do not force the issue, Nursing Management of Elderly client with
because it can lead to agitation. Chronic Confusion (delirium):
• Provide a structured environment that
ensures safety yet enables the person to 1. Consult with a geriatric specialist
keep active as long as possible. 2. Bring a full medication list to any new health
• Provide continuity professional
• Administer psychotherapeutic medications 3. 3.Make things familiar
as ordered. 4. Stay close
• Avoid use of physical and chemical restraints 5. Insist on sensory aids
• Structure participation in activities of daily 6. Promote activity
living 7. Be there for meals
• Structure the environment to minimize 8. Participate in discharge planning
disruption; avoid sudden changes of room or
Tips for Communicating with a Confused
environment.
Patient:
• Develop a plan to deal with “acting out”
behaviors. 1. Try to address the patient directly, even if his
• Use effective communication skills or her cognitive capacity is diminished
• Consult with family and the multidisciplinary 2. Gain the person's attention
team. 3. Speak distinctly and at a natural rate of
speed

6
 4. Help orient the patient
5. If possible, meet in surroundings familiar to
the patient
Nursing interventions/implementation
6. Support and reassure the patient
NURSING PROCESS FOR IMPAIRED VERBAL
COMMUNICATION
Definition: Decreased, delayed, or absent ability of
an individual to receive, process, transmit, or use a
system of symbols.
Nonverbal communication- the transmission of a
message without the use of words.
• Speech: dysarthria
• Language: aphasia (or dysphasia):receptive
aphasia-in which the person has difficulty
understanding language;
expressive aphasia, in which the person is
unable to express himself or herself using
language;
and global aphasia, in which the person
loses the ability both to understand
language and to express himself or herself
using language.
Signs and Symptoms of Elderly with Impaired
Communication:
• Difficulty vocalizing words
• Difficulty discerning and maintaining the
usual communication pattern
• Disturbances in cognitive associations
• Inability to find, recognize, or understand
words
• Inability to recall familiar words, phrases, or
names of known people, objects, and places
• Inappropriate verbalization
• Problems in receiving the type of sensory
input being sent or sending the type of input
necessary for understanding
Nursing diagnosis
Impaired verbal communication
Nursing goals/outcomes identification
The nursing goals for older individuals with impaired
verbal communication are to
• communicate needs with minimal frustration;
• demonstrate an increased ability to
communicate needs and feelings; and
7
• express satisfaction with or acceptance of
alternative methods of communication.
• Assess the older adult’s communication problems
and abilities.
• Identify specific approaches that are effective for
each person. Many techniques can facilitate
communication; try a variety of these to
determine which are most effective. When
working with an older adult with impaired verbal
communication, use the following approaches:
(1) face the person when speaking, and
establish eye contact; (2) speak slowly and
clearly and in a low tone of voice; (3) speak in a
normal tone of voice, and avoid shouting; (4)
allow adequate time for communication (do not
hurry the communication); (5) pace communi
cation to avoid fatigue; (6) keep messages
simple with one or twoword phrases; and (7)
use touch therapeutically.
• Document in the care plan the selected
techniques that facilitate communication
• Explain effective communication techniques to
family members and friends
• Teach verbally impaired older adults methods for
their specific communicating needs.
• Consult with a speech therapist/pathologist to
determine the most effective communication
strategies
• Learn patient needs and pay attention to
nonverbal cues Place important objects within
reach
• Provide an alternative means of communication
for times when interpreters are not available
(e.g., a phone contact who can interpret the
patient’s needs).
• Never talk in front of patient as though he or she
comprehends nothing.
• Give the patient ample time to respond.
• Maintain a calm, unhurried manner. Provide
sufficient time for patient to respond.
• Involve family and significant others in plan of care
as much as possible.
• Provide word-and-phrase cards, writing pad and
pencil, or picture board. Use eye blinks or finger
movements for “yes” or “no” responses.
• Try to phrase questions requiring a “yes” and “no”
answers. Use short sentences, and ask only one
question at a time.
• Keep distractions such as television and radio at a
minimum when talking to patient.
• Praise patient’s accomplishments. Acknowledge
his or her frustrations.
• Involve family and significant others in plan of care
as much as possible.
 Core Elements of Evidence-Based
Gerontological Nursing Practice
Why Standard is set to Gerontologic Nursing?
• This standard was developed todescribes
health and well being of gerontological
nurses on how to care for older person’s
health, recovery to well being and comfort.
• “The primary purpose of standards is to
provide direction for professional practice in
order to promote competent, safe and
ethical service for clients”
PURPOSE OF STANDARDS OF PRACTICE:
• Define the scope and depth of gerontological
nursing practice
• Establish criteria and expectations for high
quality nursing practice and safe, ethical
care
• Provide criteria for measuring actual and
desired performance
• Support ongoing development of
gerontological nursing
• Promote gerontological nursing as a
specialty, providing the foundation for
certification of gerontological nursing by the
Canadian Nurses Association
• Promote components of gerontological
nursing knowledge as entry-to-practice
competencies,setting a benchmark for new
graduates
• Inspire excellence in and commitment to
gerontological nursing practice
USING THE STANDARDS OF PRACTICE
• Nurses in clinical practice use the
standards to guide and evaluate their
practice
• Nursing educators include the standards
in course curricula to prepare new graduates
for gerontological practice across all settings
• Nurse administrators use the standards
to direct policy and guide performance
expectations
8
• Nurse researchers use the standards to
measure and guide the development of
knowledge specific to gerontological nursing
• Nurse advocates use the standards to
support social justice initiatives for policy
change at local community, provincial and
national levels
STANDARDS GERONTOLOGICAL NURSING
PRACTICE:
Standard I : Humanistic and Relational Care
• Humanistic approach to provide high-quality
care for older people and their care partners
and is dependent upon empathy and
understanding
• Assessing need for and encouraging
friendship and social relationships between
older people and those who are meaningful
to the older person
• Communicating effectively, respectfully,
person- centred and compassionately with
older people and their care partners (e.g.,
recognizing and working with individual
characteristics of older people living with
dementia, hearing loss, social determinants
of health and other)
• Appreciating the influence of attitudes, roles,
language, culture, race, religion, gender, and
lifestyle on older people and their care
partners’ views of health, wellbeing, illness,
aging and perceptions of care delivery
• Assuring participation of older people and
their care partners in decision making (e.g.
treatments, advance care planning, health
care proxy, informed consent, elder abuse
reporting, legal guardianship, wills, and any
other decision-making point from the
perspective of the older person)
• Assessing care partners’ knowledge, skills,
and needs, as well as their experiences (e.g.
coping strategies, preferences/wishes,
impact on health, burden) when providing
care to older people
Standard II : Ethical Care
• Gerontological nurses recognize that the
ethical care of older people and their care
partners will involve clarification of conflicting
values and exploring alternatives
• Self-determination and freedom of
expression
 • Creating ethical workplaces -way to govern
themselves and their overall work attitude -
morality
• Providing ethical leadership - put people into
management and leadership positions to
promote and be example of appropriate,
ethical conduct in their actions and
relationships in the workplace.
• Mitigating the moral distress of nursing
colleagues- “Talk about it” Organizational
leaders must talk about moral distress and
its counterpart, moral resilience. Keeping
silent and not addressing the issue can
cause harm. Empowering nurses to speak up
and even challenge decisions when
appropriate is critical.
• Reporting professional misconduct and
negligence- an act that results in dispute to
his profession and make him unfit of being
in the profession
Standard III : Evidence- Informed Care
• Design health promoting programs and
activities using information about what
works
• Patients receive care that is informed by
clinical expertise, patient values and best
available research evidence.
• Understanding and consideration of normal
age related changes
• Completing a nursing history and
examinations when there is a change in
health status, setting, or well- being.
• Performing interventions.
o screening, immunization, risk-
assessment
o prevent disease, injury and excess
disability, promote rehabilitation,
and provide palliative care
Standard IV : Aesthetic/Artful Care
• Promoting an environment within which the
older person and care partner are free to
express their concerns, hope, dreams,
feelings, values and beliefs.
• Collaborating with inter-professional team
members to advocate for adequate
equipment for older people to engage in
meaningful activities .
• Need for music, warmth, comfort, food,
artistic elements, presence of familiar people
or objects.
9
Standard V : Safe Care
• Gerontological nurses are responsible for
assessing the older person and the
environment for hazards that threaten
safety, as well as planning and intervening
appropriately to maintain a safe
environment .
• Equipment requirements for maintaining
safety (e.g. transfers, mobility, stairs)
• Food security.
• Access to safe and affordable housing.
• Maximizing self-care (e.g. immunizations,
accident prevention)
• Assessment, prevention and mitigation of all
forms of abuse.
Standard VI : Soci-Political Engaged Care
• Collaborating with a variety of public and
professional organizations as well as other
stakeholders to influence building of health
policy.Identifying and evaluating the
accessibility, availability, and affordability of
health care for older adults to promote their
goals.
• Lobbying governmental policy makers to
influence building of health policy using
comprehensive strategies such as electronic
and social media, letters to officials, briefing
notes, letters to the editor, media releases
and resolutions.
Final Note:
• The above Standards and Competencies aim
to promote gerontological nursing research
and best practices across a variety of
settings.
• Standards and Competencies to guide
gerontological nursing practice and care
delivery. CGNA members believe that our
Standards and Competencies document
demonstrates that gerontological nursing is
a vibrant, exciting, evidence-informed
practice specialty. We believe that
‘gerontological nursing is a conscious choice
COMPETENCIES of GERONTOLOGIC
NURSING:
• Competencies specific to gerontological
nursing promote highest quality of care
• Basic competencies:
 1. Normal from abnormal findings – (at
risks)
2. Assessment – empowerment (choose
how they want to demonstrate
knowledge, ideas, and concepts )
3. Engage older adults in all care -
preferences identified
4. Education - assist older adults in care
needs & give health teachings
5. Individualized care- facilitate advanced
directives (make important decisions
during a crisis)
PRINICIPLES OF GERONTOLOGIC NURSING :
Proven facts of theories that guide nursing actions -
to improve practice by positively influence the health
and quality of life of patients
1. Florence Nightingale: Environmental theory ;
2. Betty Neuman: Neuman systems model;
3. Callista Roy: Adaptation model of nursing;\
4. Dorothea Orem: Self-care deficit nursing
theory;
5. Faye Abdellah: Patient-centered approach to
Nursing.
• Foundation of nursing practice - supporting
patient- centered to improve relationships
and strengthen the professional aspects of
care - works with nurses to develop,
promote and improve patient care.
• Direct care delivery - provided personally by
a staff member –involvement treatments,
counselling, self- care, patient education and
administration of medication.
ISSUES / CONCERNS OF GERONTOLOGIC
NURSING
• Geriatric nursing is an area of nursing that
specializes in the care of aging patients.
• Nurses help manage patients with age-
related disease processes such as
osteoporosis, Alzheimer's disease/
dementia, chronic pain, arthritis, and
impaired mobility and self-care.
• As with any area of nursing, geriatric nursing
presents a unique set of challenges.
Death and Dying:
• Most significant challenges is death and
dying -challenging for the patient , family but
caregivers .
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• Nurses grieve- they should identify their
coping mechanisms and have healthy outlet
for their feelings; feelings of guilt
• Facing the issue of death - nurse’s have
feelings of mortality - that lead to anxiety
and depression.
Dementia:
• Nurses and families dealing with dementia
must be patient and calm.
• It's easy for people to get frustrated with
patients with memory ailments, and
frequent, repetitive instructions may be
necessary.
• Nurses should educate families about the
disease process of dementia and provide tips
on coping with the day-to-day care of
patients with this disease.
• Offering respite resources for families is also
crucial, but caregiver respite is also essential.
• Taking breaks helps recharge nurses and
help
Self-care
• Impaired mobility, memory disturbances, and
illness interfere with an individual's ability to
take care of oneself.
• Nurses may have to care for patients after a
fall and are sometimes at the bedside to
witness the physical deterioration of mobility
and the ability for older adults to take care
of themselves independently.
• Families must often decide for 24-hour care,
whether it's with them or in a care facility,
and geriatric nurses are usually the ones to
provide resources for care.(PDN) or admit
in a Hospice Care.
Abuse/Neglect;
• Abuse and neglect - families' inability to give
complex care of their aging family member,
financial problems, or mental illnesses.
• Geriatric nurses must be able to identify
abuse and neglect and take the appropriate
action to protect the patient.
• It is painful and disheartening to witness
abuse.
• Nurses may face depression and
hopelessness.
• Nurses should be able to identify a healthy
outlet for their feelings and frustrations.
ETHICO-LEGAL CONSIDERATIONS IN THE
CARE OF OLDER ADULT:
A. LAWS AFFECTING SENIOR
CITIZENS/OLDER PERSONS
1. Republic act no. 7432 - an act to
maximize the contribution of senior citizens
to nation building, grant benefits and special
privileges and for other purposes. Section 1.
(february 7, 1992)
2. Republic act no. 9257 - an act granting
additional benefits and privileges to senior
citizens amending for the purpose republic
act no. 7432, otherwise known as “an act to
maximize the contribution of Senior citizens
to nation building, grant benefits and special
privileges and for other purposes” ( july 28,
2003 )
3. Republic act no. 9994 - as provided in
the constitution of the republic of the
philippines, it is the declared policy of the
state to promote a just and dynamic social
order that will ensure the Prosperity and
independence of the nation and free the
people from poverty through policies that
provide adequate social services, promote
full employment, a rising standard of living
and an improved quality of life. (july 27,
2009) expanded senior citizen act of 2010
Privileges of a senior citizen:
List of Senior Citizen Benefits
• Income tax exemption for minimum wage
earners.
• Training fee exemption on socio-economic
programs.
• Free medical and dental services in
government facilities.
• Free flu and pneumococcal vaccinations for
indigent senior citizens.
Who are considered senior citizens in the
Philippines?
SENIOR CITIZEN OR ELDERLY - refers to any Filipino
citizen who is a resident of the Philippines sixty (60)
years old or above. It may apply to senior citizens with
"dual citizenship" status provided they prove their
Filipino citizenship and have at least six (6) months
residency in the Philippines.
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B. MEDICATIONS OF OLDER ADULTS
Serious consideration should be given when
prescribing for the elderly:
1. Allowing the elderly and their families to be
involved in their treatment; social support;
and cost-benefit considerations.
Side-Effects Affecting Thinking And Balance
1. “ANTICHOLINERGICS,” -drugs for overactive
bladder, itching/allergy, vertigo, nausea, and certain
drugs for nerve pain or depression. Diphenhydramine,
or Benadryl -over-the-counter sleep aids and
painkillers.
2. SEDATIVES AND TRANQUILIZERS, which are often
prescribed for sleep or for anxiety (zolpidem and
lorazepam (brand names Ambien and Ativan)-
increase fall risk, provoke confusion. Geriatricians
commonly recommending stopping or reducing the
dosage of these drugs.
Symptoms persisting despite drug treatment:
Started drug for a certain symptom, such as pain,
heartburn, incontinence, or depression. Too busy for
doctors visit and even patients postpone following up
on the symptom indefinitely.
• In many cases, a “starter dose” is prescribed,
but is not adjusted.
• Older adults may end up with the risks and
burden of taking a drug — including the
cost of the drug — while not getting much
benefit from the drug.
• Geriatricians usually try to make sure that all
drugs for symptoms are serving a useful
purpose in improving wellbeing or quality of
life.
3. “ANTICHOLINERGICS,” -drugs for overactive
bladder, itching/allergy, vertigo, nausea, and certain
drugs for nerve pain or depression. Diphenhydramine,
or Benadryl -over-the-counter sleep aids and
painkillers.
4. SEDATIVES AND TRANQUILIZERS, which are often
prescribed for sleep or for anxiety (zolpidem and
lorazepam (brand names Ambien and Ativan)-
increase fall risk, provoke confusion. Geriatricians
commonly recommending stopping or reducing the
dosage of these drugs
Symptoms persisting despite drug treatment:
Started drug for a certain symptom, such as pain,
heartburn, incontinence, or depression. Too busy for
doctors visit and even patients postpone following up
on the symptom indefinitely.
• In many cases, a “starter dose” is prescribed,
but is not adjusted.
• Older adults may end up with the risks and
burden of taking a drug — including the
cost of the drug — while not getting much
benefit from the drug.
• Geriatricians usually try to make sure that all
drugs for symptoms are serving a useful
purpose in improving wellbeing or quality of
life.
Drug Interactions
• Warfarin is one of the most common causes
of medication-related hospitalizations in
older adults.
• To reduce the risk of serious problems, one
may need to apply extra care in monitoring
warfarin effect (via the prothrombin blood
test) and extra care in checking for
interactions when a new drug is prescribe
• Warfarin - Preventing harmful blood clots
helps to reduce the risk of a stroke or heart
attack.
• Warfarin is commonly called a "blood
thinner," - anticoagulant.
Side-Effects Due To A Strong Effect Of Drugs On The
Older Person.
Examples of this include:
• Blood pressure medications - lower blood
pressure(lightheadedness, or even falls,
when an older person stands
• Blood sugar lowered by diabetes drugs. Low
blood sugar cause falls and have been linked
to faster cognitive decline.
• Drugs that lower blood sugar are involved
medication-related hospitalizations.
Burden Of Scheduling And Taking
Medication:
• Many older adults end up with several pills to
take at several different times per day – it
create hassle; makes you drain on quality of
life.
• Some older adults are unable to take all their
medications properly.
• Medications are missed cause serious effects
on an older person’s health.
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Cost Of Medication:
• Monthly costs of medications can be high-
limited financial resources.
• Cause people to skip taking certain
medications, or not fill prescriptions for more
expensive medications (such as inhalers).
C. ETHICAL PRINCIPLES:
BENEFICENCE - good health and welfare of the
patient
NONMALEFICENCE - intentionally action that cause
harm.
AUTONOMY AND CONFIDENTIALITY - autonomy
(freedom to decide; right to
refuse)confidentiality(private information)
SOCIAL JUSTICE - view that everyone deserves equal
economic, political and social rights and opportunities
PROCEDURAL JUSTICE - fairness and the
transparency of the processes by which decisions are
made
VERACITY - truthfulness or accuracy.
FIDELITY - quality of faithfulness or loyalty.
D. LONG TERM CARE
LTC supports older adults in two distinct realms:
• Activities of daily living (ADLs) eating,
bathing, dressing, getting into and out of
bed or a chair, and using the toilet.
• Instrumental activities of daily living (IADLs)
include managing finances, handling
transportation, shopping, preparing meals,
using the telephone or other communication
devices, managing medications, doing
laundry, housework, and basic home
maintenance.
Is long term care only for the elderly?
Myth: Long term care is only for the elderly.
Fact: The need for long term care can arise at any time
in a person's life.
• While the majority of people who require long
term care are elderly,
• younger people can require it anytime due to
severe unexpected illnesses, diseases,
injuries or accidents.
Persons Who Qualified For Long Term Care:
• Must be at least 65 years of age and
• Unable to perform, without assistance at
least two (out of five) Activities of Daily
Living (ADLs). The five ADLs considered are:
bathing, dressing, toileting, transferring and
eating.
E. PALLATIVE CARE
Definition: Palliative care is whole-person care. It can
help patients manage the stress and burden of a
serious illness and help them achieve their definition
of quality of life.
Palliative care can help patients cope with aggressive
treatments by getting pain and side effects under
control to help them fight the disease.
• Primary goal of palliative care is to provide
the best quality of life possible at the end of
life for both patients and families of
terminally ill patients.
• Illness and dying may affect the elderly and
their families differently from younger
individuals.
• Palliative care does serve many people with
life-threatening or terminal illnesses.
• Palliative care also helps patients stay on
track with their health care goals.
Principles of Palliative Care
1. Provides relief from pain and other distressing
symptoms;
2. Affirms life and regards dying as a normal process;
3. Intends neither to hasten or postpone death;
4. Integrates the psychological and spiritual aspects of
patient care;
5. Offers a support system to help patients live as
actively as possible until death.
Palliative care specialists treat people living
with many disease types and chronic
illnesses.
• Cancer
• Cardiac disease - congestive heart failure
(CHF),
• Chronic obstructive pulmonary disease
(COPD),
• Kidney failure
• Alzheimer’s disease
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• Parkinson’s disease
• Multiple Sclerosis
Difference Between Palliative Care And
Hospice:
• Both palliative care and hospice care provide
comfort.
• But palliative care can begin at diagnosis, and
at the same time as treatment.
• Hospice care begins after treatment of the
disease is stopped and when it is clear that
the person is not going to survive the illness
F. ADVANCE DIRECTIVES/DNR:
Definition: A legal document that states a person's
wishes about receiving medical care if that person is
no longer able to make medical decisions because of
a serious illness or injury.
• Do Not Resuscitate (DNR) order is one type
of advance directive. This allows you to
decide NOT to undergo cardiopulmonary
resuscitation (CPR) or other treatments
which will try to revive if the heart stops or if
it stop breathing.
Types of advance directives:
• The living will- a written statement detailing
a person's desires regarding their medical
treatment in circumstances in which they are
no longer able to express informed consent.
• Durable power of attorney for health
care/Medical power of attorney. – It allows
client to designate an agent to make all
decisions about their health care if unable to
make decisions to one self.
• POLST (Physician Orders for Life-Sustaining
Treatment) - is a physician’s order that
outlines a plan of end of life care reflecting
both a patient’s preferences concerning care
at life’s end and a physician’s judgment
based on a medical evaluation.
• Do not resuscitate (DNR) orders. - is a
medical order written by a doctor. It instructs
health care providers not to do
cardiopulmonary resuscitation (CPR) if a
patient's breathing stops or if the patient's
heart stops beating.
• An advance directive isn't the same as a DNR
G. END OF LIFE CARE
Definition:
• A support for people who are in the last
months or years of their life.
• Helps client to live as well as possible until
they die and to die with dignity.
• You can receive end of life care at home, care
homes, hospices or hospitals, depending on
their needs and preference.
How Long Does End of Life Care last?
• End of life care should begin when you need
it and may last a few days, or for months or
years.
• Some of them may be expected to die within
the next few hours or days
Symptoms During the Final Months, Weeks,
and Days of Life
• Delirium -many causes at the end of life
• Fatigue -most common symptoms in the last
days of life.
• Shortness of Breath
• Pain
• Cough
• Constipation
• Trouble Swallowing
• Death Rattle - a gurgling sound - no longer
able to swallow or cough, saliva builds up in
the back of the throat and the airways
causing a "rattling" sound when air passes
through.
Organ that shut/close down first when dying:
is the DIGESTIVE SYSTEM. Digestion is a lot of work!
In the last few weeks, there is really no need to
process food to build new cells.
• loss of appetite
Organ last to die in a dying person:
• BRAIN AND NERVE CELLS require a
constant supply of oxygen and will die within
a few minutes, once you stop breathing.
• The next to go will be the heart,
• Followed by the liver, then the kidneys and
pancreas, which can last for about an hour.
• Skin, tendons, heart valves and corneas will
still be alive after a day.
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H. SPIRITUALITY AMONG OLDER PERSONS
• Spiritual care may assist older people to cope
better with their transition to residential aged
care and in their longer-term residency.
• Spiritual assessment - unique spiritual beliefs
and practices.
Spiritual needs of an older person:
• Need for support in dealing with loss.
• Need to transcend circumstances.
• Need to be forgiven and to forgive.
• Need to find meaning, purpose and hope.
• Need to love and serve others.
• Need for unconditional love.
• Need to feel that God is on their side.
• Need to be thankful.
I. ETHICAL DILEMMAS
Main Ethical Dilemma regarding geriatric clients:
• Ensuring informed consent and
confidentiality
• Determining decision-making capacity
• Promoting advance care planning –
preference
• Use of advance directives, surrogate decision
making, withdrawing and withholding
interventions, using cardiopulmonary
resuscitation and DNR.
Ethical problems that exist in nursing homes:
• Decision-making in end-of-life care
• Use of restraints
• Lack of resources.
Legal and Ethical issues that occur with end of life
patient:
• Patients' decision-making capacity and right
to refuse treatment;
• Withholding and withdrawing life-sustaining
treatment- nutrition and hydration; "no code"
decisions;
• Medical futility - interventions that are do not
produce any significant benefit for the
patient.
• Assisted suicide - patient suffering from
incurable disease -by the taking of lethal
drugs provided by a doctor for this purpose.
VI. COMMUNICATING WITH OLDER PERSON:
A. INFORMATION SHARING:
• Allow extra time for older patients - receive
less information from physician/health care
team
• Avoid distractions - feel quality time with
them and that they are important. Reduce
visual and auditory distractions, such as
other people and background noise.
• Sit face to face -reading your lips is not easy
for them to receive the information. Sitting
in front reduce distraction. Patient
compliance with treatment is good if the
physician is face to face with the patient
when offering information about the illness.
• Maintain eye contact. Eye contact -
nonverbal. It tells patients that you are
interested in them and they can trustyou.
• Listen - doctors is that they don’t listen.
Good communication depends on good
listening. Many of the problems associated
with noncompliance can be reduced or
eliminated simply by taking time to listen to
what the patient has to say.
• Speak slowly, clearly and loudly - older
person learns is slower than younger
person. Don’t rush through your instructions
to these patients. Speak clearly and loudly
enough for them to hear you, but do not
shout.
• Use short, simple words and sentences.
Simple information can easily be
understood and this makes the client follow
your instructions.
• Stick to one topic at a time. Avoid long,
detailed explanation to a patient, try the
information in outline form. Explain
important information in a series of steps-
first talk about the heart; second, talk about
blood pressure; and third, talk about treating
blood pressure.
• Simplify and write down your instructions.
Writing is a permanent form of
communication than speaking and provides
the opportunity for the patient to later
• Use charts, models and pictures. Visual aids
will help patients better understand their
condition and treatment.
• Frequently summarize the most important
points- ask them to repeat your instructions.
• Give patients an opportunity to ask questions
and express themselves - give your patients
ample opportunity to ask questions- makes
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less apprehensive- determine if completely
understand the information
• Information sharing (framing the message)
Verbal communication involves sending and receiving
messages by means of words:
o FORMAL (structured, precise)
o INFORMAL (unstructured, flexible)
• Formal or therapeutic communications have
a specific intent and purpose.
• Informal or social conversations are less
specific and are used for socialization.
Nonverbal communication - without words ; 7% actual
words we use; 93% is nonverbal ; 38% paralinguistic
cues (tone, pitch and volume of voice); 55% body
cues. The importance of understanding nonverbal
communication can be summed up in the statement,
“What you are saying (nonverbally) is so loud I can’t
hear you.”
FORMAL OR THERAPEUTIC
COMMUNICATION:
• Collection of techniques that prioritize the
physical, mental, and emotional well-being
of patients.
• Nurses provide patients with support and
information while maintaining a level of
professional distance and objectivity.
Types Of Therapeutic Communication:
Therapeutic communication:
• VERBAL
• NONVERBAL
• Effective therapeutic communication often
involves:
Active listening - in part, paying attention to what
a client is really saying.
Therapeutic Communication Techniques:
Using Silence - it’s useful to not speak at all -give
nurses and patients to think through and process
what comes next in the conversation
Accepting - simply make eye contact and say “Yes, I
understand.” Patients who feel their nurses are
listening to them and taking them seriously are more
likely to be receptive to care.
Giving Recognition -acknowledges a patient’s
behavior and highlights it without giving an overt
compliment. “I noticed you took all of your
medications” draws attention to the action .
Offering Self-nurses offer their time, it shows they
value patients .Offering to stay for lunch, watch a TV
show, or simply sit with patients for a while can help
boost their mood.
Giving Broad Openings -patients direct the flow of
conversation and decide what to talk about - “What’s
on your mind today?” or “What would you like to talk
about?” can be a good way to allow patients an
opportunity to discuss what’s on their mind.
Active Listening – non verbal cues by nodding and
saying ”I see” encourages to continue talking
Seekin.g Clarification – if says something confusing -
ask “ I’m not sure I understand can yo explain it to
me?
Placing the Event in Time or Sequence- It forces
patients to think about the sequence of events and
may prompt them to remember something they
otherwise wouldn’t.
• Focusing - Nurses can focus on their
statement, prompting patients to discuss it
further.
• Confronting - Confrontation, when used
correctly, can help patients break
destructive routines or understand the state
of their situation.
• Voicing Doubt - By expressing doubt, nurses
can force patients to examine their doings.
• Offering Hope and Humor - This technique
can keep patients in a more positive state
of mind.
• Learn Nursing Communication Skills -
online nursing degrees teach the
communication skills needed to excel in
nursing -provide nurses with a challenging,
flexible learning

Making Observations - Observing that they look tired

may prompt patients to explain why they haven’t
been getting much sleep lately; making an
observation that they haven’t been eating much may
lead to the discovery of a new symptom.

Encouraging Descriptions of Perception

1. Hallucinations - ask about them in an

encouraging, non- judgmental way.

2. Phrases like “What do you hear now?” or

“What does that look like to you?” patients
explain what they’re perceiving without
casting their perceptions in a negative way.

Encouraging Comparison

Nurses can help patients discover solutions to their

problems.

Summarizing - to summarize what patients have

said after the fact is helpful – it makes patients think
that the nurse was listening and allows the nurse to
document conversations. i.e. “Does that sound
correct?” gives patients permission to make
corrections if they’re necessary.

Reflecting - Nurses can ask patients what they

think they should do, which encourages patients to
be accountable for their own actions and helps them
come up with solutions themselves.

16

Barriers to communication
• LANGUAGE DIFFERENCES
inability to communicate affects response to
interventions
• CULTURAL DIFFERENCES – some culture
express feeling spontaneously , some are
reserved in verbalization.
• GENDER - sending, receiving, and
interpreting messages can vary between
men and women -women are better
decoders of nonverbal cues.
• HEALTH STATUS -client who is oriented will
communicate more reliably than a client
who is delirious, confused, or disoriented.
• DEVELOPMENTAL LEVEL - communicating
with children requires the use of different
17
words and approaches than those used with
adults.
• KNOWLEDGE DIFFERENCES – nurse should
know the knowledge levels of clients in
order to give correct method of instruction.
• EMOTIONAL DISTANCE - is affected if a
client is on isolation because of infectious
disease is at risk for emotional isolation.
• EMOTIONS - if client is anxious,
communication may change, stop, or take a
nonproductive effect.
• DAYDREAMING - Mind-wandering can also
happen because the listener is bored or
preoccupied with worrisome thoughts.
Nurse allow them to do so but stay
alert and control their own thoughts.
• USE OF HEALTH CARE JARGONS - nurses
use language that is easily understood and
explain medical terminology so that it is
clear to clients and families.
Checklist in overcoming language barriers:
• Speak slowly and distinctly in a normal tone
of voice.
• Use gestures or pictures to emphasize
meaning of words.
• Avoid clichés , medical jargon, or value-laden
terms.
• Avoid defensive or challenging body
language.
• Provide reading material written in the
appropriate language.
• Use an interpreter who is fluent in health care
- terminology.
• Speak to the client rather than to the
interpreter.
• Use the same interpreter for every interaction
if feasible.
INFORMAL OR SOCIAL COMMUNICATION
Informal communication is casual communication
between coworkers in the workplace. It is unofficial in
nature and is based in the informal, social
relationships that are formed in a workplace outside
of the normal hierarchy of business structure.
Therapeutic communication
Therapeutic communication is the use of
communication for the purpose of creating a
beneficial outcome for the client. Therapeutic
communication:

• Is purposeful and goal-directed

• Has well-defined boundaries
• Is client-focused
• RESPECTING OUR DIFFERENCES
• Interpreting Nonverbal Behavior
• Never assume that a nonverbal behavior has
the same meaning for everyone.
Interpretation of various nonverbal aspects
of communication varies among people
because of developmental, cultural,and
experiential factors.
• Is nonjudgmental
• Uses well-planned, selected techniques
• Ruesch (1961), who originated the term
therapeutic communication, stated that the
purpose is to improve the client’s ability to
function. Furthermore, therapeutic
communication facilitates the establishment
of the nurse-client relationship and fulfills
the purposes of nursing (Kneisl, 2009).
Therapeutic communication forms a
connection between client and nurse.
Technological advances cannot replace the
need for communication between client and
nurse. The ‘‘high-tech’’ environment
demands the presence of ‘‘high-touch’’
nursing care.

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