Integrated Nursing Practice II

Session 1
OLDER PERSONS

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 References
Fundamentals of Nursing
• Chapter 24: Older Persons

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 Learning Objectives
• To understand course performance criteria and expectations
• To review rules, policies and procedures related to lab
practice
• To discuss the existing myths and stereotypes that are related
to the older adult and incorporate the learning needs of the
older adult.
– Myths and stereotypes that are related to the older adult
– Learning needs of the older adult.
• To practice in collaboration with clients including older adults,
the inter-professional healthcare team, peers and faculty.
• To identify own values, biases, and assumptions related to
older adults as a self-reflective, responsible and accountable
practitioner.
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 Learning Objectives
• To review how data is collected when assessing the older adult including
assessment for chronic illness in various settings where the older adult
may be encountered.
– Physiological changes – review each body system
– Functional changes
– Cognitive changes
– Delirium
– Dementia
– Depression
– Psychosocial changes
– Retirement
– Social isolation
– Abuse
– Sexuality
– Housing and environment

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 Learning Objectives
• To identify and understand the cognitive changes that may be
encountered in relation to the older adult including the differences
between delirium, dementia, and depression.
• To discuss the changes for the older adult in relation to sexuality.
• To identify potential sources of violence in residential, and home, and
community care

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 Older Persons
• Age of 65 years is used as the lower boundary
to define older adulthood in demographics
and social policy.
• This population is sometimes divided into
groups of youngest old, old, and oldest old
(oldest old is over 85).
• Number of older persons is growing, both
absolutely and as a proportion of the total
population.
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 Variability Among Older Persons
• Great variation in physiological, cognitive, and
psychosocial health
• Levels of functional ability
• Dependence versus independence
• Strengths and abilities

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 Myths and Stereotypes
• That older persons are
– Ill and disabled
– Not interested in sex or sexual activities
– Unable to use computers
– Forgetful, confused, rigid, boring, unfriendly
– Unable to learn and understand new information
– Unattractive and worthless to society
• Ageism

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 Nurses’ Attitudes Toward Older
Persons
• Nurses need to recognize and address ageism:
– By questioning prevailing negative attitudes and
stereotypes
– By advocating for older persons
• Nurses must treat older persons as
independent, dignified persons.

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 Developmental Tasks for
Older Persons
• Adjusting to decreasing health and physical
strength
• Adjusting to retirement and reduced or fixed
income
• Adjusting to the death of a spouse
• Accepting one’s self as an aging person
• Maintaining satisfactory living arrangements
• Redefining relationships with adult children
• Finding ways to maintain quality of life
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 Aging Well and Quality of Life
• “Aging well” or active aging
• Quality of life
• Nurse’s work with older person to set
objectives

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Community-Based and Institutional
Health Care Services
• Older persons are cared for in various settings:
– Private homes, apartments, adult day care
centres, home care, personal care home, assisted-
living facilities, long-term care facilities, hospice
• Older persons may request assistance with
making decisions regarding which type of
health care service is appropriate for them.

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 Assessing the Needs of
Older Persons
• Nursing assessment:
– The interrelationship between physical and
psychosocial aspects of aging
– Effects of disease and disability on functional
status
– Decreased efficiency of homeostatic
mechanisms
– Lack of standards for defining health and illness
norms
– Altered presentation and response to specific
disease
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 Physiological Changes
• Older patients’ concept of health revolves
around how they perceive their ability to
function.
• Not all physiological changes are pathological.
• Nurses need to be cognizant of normal age-
related changes.

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 Common Physiological Changes
with Aging
• Systems
– Integumentary – Sensory
– Respiratory – Genitourinary
– Cardiovascular – Reproductive
– Gastrointestinal – Endocrine
– Musculoskeletal – Immune system
– Neurological

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 Functional Changes
• Declines in physical, psychological, cognitive,
and social function are usually linked to illness
or disease and degree of chronicity.
– Influences an older person’s functional abilities
and overall well-being
• The capacity and safe performance of
activities of daily living (ADLs) is a sensitive
indicator of health or illness in older persons.

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 Cognitive Changes
• A common misconception about aging is that
cognitive impairments are widespread among
older persons.
• Structural and physiological changes within
the brain are normal with aging.
– Symptoms such as disorientation, loss of language
skills, loss of the ability to calculate, and poor
judgement are not normal changes with aging.

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Conditions Affecting Cognition

Delirium Acute state of confusion; sudden

onset

Dementia Generalized impairment of intellectual

functioning; gradual deterioration

Depression A mood disturbance characterized by

feelings of sadness and despair

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 Psychosocial Changes
• Retirement
• Social isolation
• Abuse
• Sexuality
• Housing and environment
– Age-friendly community
• Death

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Addressing the Health Concerns of
Older Persons
• Two most common causes of death:
1. Cancer
2. Heart disease
• Other common causes of death:
– Respiratory disease, stroke, accidents, falls,
diabetes, kidney disease, and liver disease
• Preventive measures to reduce/delay all of
these conditions

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 Health Promotion and
Maintenance: Physiological Health
• Cancer
Concerns
• Arthritis
• Heart disease • Falls
• Smoking • Sensory impairments
• Alcohol abuse • Pain
• Nutrition • Medication use
• Oral health – Polypharmacy
• Exercise

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 Physiological Changes
• Box Examples of Atypical Presentation
of Illness
• TABLE Common Physiological Changes
With Aging

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 Health Promotion and
Maintenance: Psychosocial Health
Concerns
• Therapeutic communication
• Touch
• Cognitive stimulation
• Reminiscence
• Body-image interventions

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 Older Persons and the Acute
Care Setting
• This setting poses risks for adverse events:
– Delirium
– Dehydration
– Malnutrition
– Nosocomial infections
– Urinary incontinence
– Skin breakdown
– Falls

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 Older Persons
and Restorative Care
• Restorative care: two types of ongoing care
– Continues the recovery from acute illness or
surgery
– Addresses chronic conditions that affect daily
functioning
• Aim of care
– To regain or improve prior level of independence,
ADLs

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 Older Persons and Palliative Care
• Improving overall quality of life for persons
with life-limiting illness and their families
• Palliative care
– Good management of symptoms
– Interprofessional collaboration
– A focus on fostering patient and family hopes and
achieving their goals and expectations for illness
management over time

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Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada,Ltd.
 Group Activity
• In small groups have each group plan and
design a senior’s living building incorporating
the strategies from the textbook on housing
and environment.
• Assume these older adults are still
independent.

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 Class Activity
• Create a resource tool to remind older adults
of necessary screening.
How would this tool be different for those with:
– Heart disease
– Type II diabetes
– Osteoporosis
– Hypothyroidism
– Anxiety and/or depression

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 Physical Restraints
• Physical Restraints
– an object used to keep a patient in place or to
prevent harm to self or others.

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 Health Promotion and Maintenance:
Physiological Health Concerns
• Health maintenance programs have been found to have a
positive impact on the physical, mental, and social health of
older persons.
• Using creative approaches, nurses can include health
promotion activities for older persons in all health care
settings.
• Approximately 80% of older persons living at home have at
least one chronic health condition.
• The most common conditions are arthritis, high blood
pressure, back problems, chronic heart problems, cataracts,
and diabetes (CIHI, 2011).

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 Health Promotion and Maintenance:
Physiological Health Concerns
• The effect of chronic conditions on the lives of
older persons varies widely, but, in general,
chronic conditions diminish well-being and
threaten independence of older persons.
• This is particularly the case when an older
person has more than one chronic condition.
• . Nursing interventions are often directed at
the management of these conditions, but
interventions can also focus on prevention.
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 Health Promotion and Maintenance:
Physiological Health Concerns
• Nurses can recommend the following general
preventive measures
– Regular exercise
– Weight reduction if the older person is overweight
– Management of hypertension
– Smoking cessation
– Immunization for influenza, pneumococcal
pneumonia, and tetanus

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 Health Promotion and Maintenance:
Psychosocial Health Concerns
• Interventions supporting psychosocial health of older
persons resemble those for other age groups.
• However, some interventions are more crucial for
older persons experiencing social isolation, cognitive
impairment, or stresses related to retirement,
relocation, or approaching death.
• These interventions include therapeutic
communication, touch, cognitive stimulation,
reminiscence, and measures to improve body image

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 Physiological Concerns of Aging
• Group Activity
• Assign one or more of the physiological
concerns of aging, listed on the next slide, to
small groups.
• Groups to summarize the concern and discuss
the role of education, prevention and risk
factors.

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 Group Activity
• Cancer • Exercise
• Heart Disease • Arthritis
• Smoking • Falls
• Alcohol Abuse • Sensory Impairments
• Nutrition • Pain
• Oral Health • Medication use

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 Fall Prevention in Health Care
Agencies
• Box 14.1 Components of Evidence-Based Fall Prevention
Interventions in Health Care Settings
• Patient falls are a recurrent problem in health care agencies.
• A fall may result in fractures, bruises, lacerations, or internal
bleeding, leading to increased diagnostic tests and
treatments, extended hospital stays, and discharge to
rehabilitation or long-term care instead of home.
• Research shows that approximately one third of falls can be
prevented (AHRQ, 2013a).

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 Fall Prevention in Health Care
Agencies
• Fall prevention involves identifying and managing a
patient's underlying fall risk factors and optimizing
the physical design and environment of the health
care agency.
• Falls are multifactorial.
• Individual intrinsic factors such as co-morbidities,
muscle weakness, and urinary incontinence increase
the risk of falling in a hospital and community setting

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 Fall Prevention in Health Care
Agencies
• Transient factors that can change over time such as
postural hypotension, polypharmacy, and use of
high-risk medications also are fall risks
• . Extrinsic fall risks such as the environment of a
health care agency (e.g., poor lighting, slippery
flooring, and improper use of assist devices) also
contribute to falls
• As a nurse your role is to assess these factors in each
patient and determine the most suitable preventive
interventions that match the patient's risks and
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 Fall Prevention in Health Care
Agencies
• Skill 14.1 Fall Prevention in Health Care
Agencies
• Box 14.1 Components of Evidence-Based Fall
Prevention Interventions in Health Care
Settings

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 Class Activity
• Review the risk factors for falls in the long-
term care facility.
• Discuss and review Skill 14.1 Fall Prevention
in Health Care Agencies

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 Recording and Reporting
• Record fall risk assessment findings, specific interventions
used to prevent falls, and patient's response to teach-back in
care plan on flow sheet or in nurses' notes in electronic health
record (EHR) or chart.
• Report to health care personnel specific risks to patient's
safety and measures taken to minimize risks
• Document your evaluation of patient and family caregiver
learning

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 Recording and Reporting
• If a fall occurs, document a description of the
fall as given by patient or you as witness. Be
sure to include baseline assessment, any
injuries noted, tests or treatments given,
follow-up care, and additional safety
precautions taken after fall.
• Complete an agency adverse event report.

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 Designing a Restraint-Free
Environment
• A physical restraint is any manual method, physical or
mechanical device (such as full set of side rails),
material, or equipment that immobilizes or reduces
the ability of a patient to move his or her arms, legs,
body, or head freely
• Chemical restraints are medications such as
anxiolytics and sedatives used to manage a patient's
behavior and are not a standard treatment or dosage
for a patient's condition.

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 Designing a Restraint-Free
Environment
• Creating a restraint-free environment allows
you to have interventions in place to reduce
wandering and risk of patient falls.
• A restraint-free environment is the first goal of
care for all patients.

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 Designing a Restraint-Free
Environment
• Patients at risk for falls or wandering present
special safety challenges.
• Wandering is the meandering, aimless, or
repetitive locomotion that exposes a patient
to harm and is often in conflict with
boundaries, limits, or obstacles.

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 Designing a Restraint-Free
Environment
• It is a common problem in patients who are confused or
disoriented (e.g., patients with dementia). Interrupting a
wandering patient can increase his or her distress.
• Wandering is a persistent problem in long-term care settings.
– More frequent observation of patients, involvement of family during
visitation, and frequent reorientation are also helpful measures.

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 Designing a Restraint-Free
Environment
• Common strategies to manage wandering include:
– environmental adaptations
– use of signaling tags
– Distraction
– social interaction
– regular exercise
– circular design of a patient care unit

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 Chemical Restraints
• Chemical Restraints
– Chemical means of restraining a patient to prevent
harm to self or others.

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 Environmental Restraints
• Environmental Restraints:
– Side rails, locked doors, enclosed in a room or
ward.

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 Types of Restraints
• Vest

• Limb Restraints
– 2 Point
– 4 Point

• Mitten

• Torso Belt

• Lap Belt

• Bed Alarm

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 Least Restraint Policy
• Nurses should use a Least Restraint Policy.

• This means that other methods should be

attempted and restraints are only a last resort.

• Physical and Chemical restraints must be

ordered by a physician.

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 Alternatives to a Restraint
• Have family/friends come in.

• Re-orientate to person, place and time if possible.

• Assign client to one on one care.

• Place in view of nursing station to allow for

optimal supervision.

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 Steps to Applying a Restraint
• Ensure patient is in a comfortable and safe position.

• Secure appliance while still being able to insert 1-2 fingers

between patient and appliance.

• Check blood flow to extremities.

• Tie to a non-movable part of the bed or chair in a slip knot fashion

so that it can be easily and quickly released in an emergency.

• Document procedure.

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 Steps to Applying a Restraint
• Check patient every 15 minutes and review need for the
restraints frequently.

• Release limbs and perform ROM frequently.

• Most often restraints are applied with at least 2 people

present.

• Refer to facility rules regarding restraints as sometimes

these can only be applied by security.
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Copyright © 2009 Elsevier Canada, a division of Reed Elsevier Canada,Ltd.
 Case Scenario
• Mr. Johnson is a resident who has Alzheimer's
disease. He has previous diagnosis’s of CHF,
HTN and Type I diabetes. He needs constant
reminders and assistance with all ADL’s. Mr.
Johnson has recently become slightly more
confused that usual, the nurses have noticed
that he has become anxious, restless, agitated.

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 Case Scenario
• Using the Nursing Process come up with a care
plan for Mr. Johnson.

• What nursing diagnosis will be appropriate for

this patient.

• Think Maslow’s Hierarchy of Needs when

addressing this patient’s needs.
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