ELECTIVE 2

INTORDUCTION TO GERONTOLOGICAL NURSING

WHAT IS GERONTOLOGICAL NURSING?

- Nursing sub-specialty for older patients
- Used to be called Geriatric Nursing

GERONTOLOGICAL NURSING VS GERIATRIC NURSING

- Gerontological Nursing

o Study of aging or the aged (old people)

- Geriatric Nursing

o Medical care of the aged

GERONTOLOGICAL NURSING
• The history and development of Gerontological Nursing is rich in diversity and experiences
• Focus is on increasing life expectancy
• Increasing numbers of acute & chronic health conditions
• Nurses provide disease prevention & health promotion
• Promote positive aging

HISTORY
• Specialty formed in the early 1960’s by ANA
• Standards for Geriatric Practice; Veterans Administration funded GRECC’s at VA medical centers
(1970’s)
• Establishment of NGNA & Scope and Standards of Gerontological Nursing Practice (1980’s)
• Established Hartford Foundation Institute of Geriatric Nursing at NYU Division of Nursing (1990’s)

PIONEERS IN GERONTOLOGICAL NURSING

• Florence Nightingale
- first geriatric nurse
- Care of Sick Gentlewomen in Distressed Circumstances
• Doreen Norton
- focused career on care of the aged
- described advantages of learning geriatric care in basic education
• Learning patience, tolerance, understanding and basic nursing skills
• Witnessing the terminal stages of disease and importance of skilled nursing
care
• Preparing for the future
• Recognizing the importance of rehabilitation
• Being aware of the need to undertake research

DEFINITIONS
• Gerontology – study of aging and the aged
• Geriatrics – medical care for the aged
• Ageism – discrimination for the aged
• Gerontological nursing – nursing study of aging or the aged
• Old – years a person has lived life
• Cultural terms: elder, senior, older adult, elderly

DEFINITION OF “OLD”
• Chronological age
– young-old: 65 - 74
– middle-old: 75 - 84
– old-old (frail elderly): 85+
• Biological age

PREVIOUS STEREOTYPES OF THE OLD

• Television
• Media
 • Newspapers
• Film industry
• Commercials in magazines and on TV
• Greeting card/birthday cards

ROLES OF THE GERONTOLOGICAL NURSE

• Provider of Care
• Teacher
• Manager
• Advocate
• Research Consumer

SCOPE AND STANDARDS OF GERONTOLOGICAL NURSING PRACTICE

• SCOPE
– Assessment
– Diagnosis
– Outcome Identification
– Planning
– Implementation
– Evaluation

• STANDARDS
– Quality of Care
– Performance Appraisals
– Education
– Collegiality
– Ethics
– Collaboration
– Research
– Research Utilization

PRACTICE SETTINGS
• Acute Care Hospital

• Long-Term Care
– Assisted Living
– Intermediate Care
– Subacute or Transitional Care
– Skilled Care
– Alzheimer’s Care
– Hospice

• Rehabilitation

• Community
– Home Health Care
– Foster Care or Group Homes
– Independent Living
– Adult Day Care

CONTINUUM OF CARE
• Acute Care Hospitals
– Often the point of entry into the healthcare system
– Nurses care for older adults
– Admits older people except in L&D, post-partum & pediatrics

• Acute Rehabilitation
– Found in several settings including acute care hospitals, subacute care (transitional care), &
LTCF’s
– Goals are to maximize independence, promote maximal function, prevent complications, &
promote quality of life within a person’s strengths & limitations

• Home Health Care

– For home-bound due to severity of illness or immobility
– Usually done by a visiting nurse
 • Long Term Care Facility
– Referred to as nursing homes
– Provides support to persons of any age who lost some or all capacity for self-care
– Nurses provide planning & oversee residents
• Maintain the functional & nutritional status of residents while preventing
complications of impaired mobility

• Hospice
– To care for the dying and their families
– Centered on holistic, interdisciplinary care to help the dying “live until they die”
– Provide quality care until the last months, weeks, days or hours of their life

• Respite Care
– Provides care to give caregivers a break
– Can be done in a daycare center, at home, or ALF’s

• Continuing Care Retirement Community (CCRC)

– Provides continuum of care from independent living to skilled care all within a single campus,
with levels of care adjusted to individual needs
– Patients can move seamlessly among independent living, assisted living, skilled care, or long-
term care as their condition warrants

• Assisted Living Facilities

– Alternative for those who don’t feel safe being alone
– For those who needs help with ADL’s
– May be connected to a LTCF
– Provides healthy meals, planned activities, places to walk & exercise, and pleasant
surroundings

• Foster Care or Group Homes

– For those who can do ADL’s but with issues safety that requires supervision
– Offers more personalized supervision in a smaller, more family-like environment

• Green House Concept

– Primary purpose is to serve as a place where elders can receive assistance and support with
ADL’s & clinical care without the assistance becoming the focus of existence
– Older people retain control of ADL’s

• Adult Daycare
– For older adults who are unable to remain at home unsupervised
– Used by family members who care for the older person in their homes
– Community based program designed to meet the needs of functionally and/or cognitively
impaired adults through individual plan of care in protective setting
– Programs may be sponsored to provide socialization, meals, & therapeutic activities

DEMOGRAPHICS OF AGING IN THE PHILIPPINES

• 2018: 8,013,059 Filipinos over 60 years old (8.2%)
– 5,082,049 will be 65 years old and older
• PROJECTIONS
• Philippines will enjoy the benefits of a young population until 2030
• Growth: 4.9% (2020)
5.6% (2025)
6.3% (2030)

• Increased life expectancy

Average age: 68.5 (2017) to 74 (2018)

• Fertility

MORTALITY AND MORBIDITY IN OLDER ADULTS

• Cardiovascular diseases, all forms 18.56%
• Pneumonia 6.21%
• Malignant neoplasms, all forms 5.11%
• COPD 3.42%
• Tuberculosis, all forms 3.04%
• Diabetes mellitus 2.74%
 • GI ulcers & other GI diseases 1.42%
• Nephritis, nephrotic syndrome, nephrosis 1.19%
• Accidents and injuries 0.98%
• Chronic liver diseases & cirrhosis 0.55%
THEORIES OF AGING
 SOCIOLOGICAL THEORIES
o Changing roles, relationships, status and generational cohort impact the older adult’s ability to
adapt.
- Activity Theory
 Havighurst and Albrecht (1953)
 Conceptualized activity engagement & positive adaptation to aging
 Remaining occupied and involved is a necessary ingredient to satisfying late
life
 Associates activity as a means to prolong middle age & delay the negative
effects of old-age

- Disengagement Theory
 Cumming & Henry (1961)
 Contrast to activity theory
 Conceptualized that aging is characterized by gradual disengagement from
society and relationship
 Withdrawal from society & relationship serves to maintain social equilibrium &
promote internal reflection
 Outcome is a new equilibrium ideally satisfying to both individual and society

- Subculture Theory
 Rose (1965)
 Views older adults as a unique subculture within society formed as a
defensive response to society’s negative attitudes & the loss of status that
accompanies aging
 Conceptualized that the elderly prefer to segregate from society in an aging
subculture sharing loss of status and societal negativity regarding the aged.
 Health and mobility are key determinants of social status

- Continuity Theory
 Havighurst, Neugarten & Tobin (1968)
 Suggests that personality is well-developed by the time one reaches old-age
& tends to remain consistent across life span
 Past coping patterns occur as older adults adjust to physical, financial, &
social decline and contemplate death

- Age Stratification Theory

 Riley and associates (1972)
 Society is stratified by age groups that are the basis for acquiring resources,
roles, status, & deference from others.
 Age cohorts are influenced by their historical contexts& share similar
experiences, beliefs, attitudes, & expectations of life course transitions

- Person-Environment Fit Theory

 Lawton (1982)
 Introduced functional competence in relationship to the environment
 Conceptualized that function is affected by ego strength, mobility, health,
cognition, sensory perception & the environment
 Competency changes one’s ability to adapt to environmental needs

- Gerotranscendence Theory
 Tornstam (1994)
 Proposed that aging individuals undergo a cognitive transformation from a
materialistic, rational perspective toward oneness with the universe
 Successful transformations include a more outward or external focus,
accepting impending death without fear, an emphasis of substantive
relatiionships, intergenerational connectedness & spiritual unity with the
universe
  Activity & participation must be the result of one’s own choices which differs
from one person to another, & control over one’s life in all situation is
essential for the person’s adaptation to aging

 PSYCHOLOGICAL THEORIES
o Explain aging in terms of mental processes, emotions, attitudes, motivation and personality
development that is characterized by life stage transitions
- Human Needs Theory
 Maslow (1954)
 Five basic needs motivate human behavior in a life-long process toward need
fulfilment
 The needs are prioritized such that more basic needs take precedence
before the complex need

- Theory of Individualism
 Jung (1960)
 Personality consists of an ego and personal and collective unconsciousness
that views life from a personal or external perspective. Older adults search
for life meaning & adapt to functional & social losses

- Stages of Personality Development

 Erikson (1963)
 Personality develops in 8 sequential stages with corresponding life tasks.
The 8th phase, Integrity vs. Despair, is characterized by evaluating life
accomplishments; struggles including letting go, accepting care, detachment,
& physical & mental decline
 Peck (1968) refined the 8th phase into three challenges
o Ego differentiation vs. work role reoccupation
o Body transcendence vs. body preoccupation
o Ego transcendence vs. ego preoccupation

- Life Course (Life Span) Paradigm

 Bühler (1933)
 Blend key elements in psychological theories (life stages, tasks, & personality
development) with sociological concepts (role behavior & interrelationship
between individual & society)
 Life course is unique to each individual
 Divided into stages with predictable patterns
 Structured based on one’s role, relationships, internal values, & goals
 Goal achievement is associated with life satisfaction

- Selective Optimization with Compensation Theory

 Baltes (1987)
 Individual copes with the functional losses of aging through activity/role
selection, optimization, & compensation
 Critical life points are morbidity, mortality, & quality of life
 Facilitates successful aging

 BIOLOGICAL THEORIES
o Stochastic Theories
- Based on random events that cause cellular damage that accumulates as organism
ages
 Free Radical Theory
o Membranes, nucleic acids, and proteins are damaged by free
radicals which causes cellular injury and aging

 Orgel/Error Theory
o Errors in DNA and RNA synthesis occur with aging

 Wear & Tear Theory

o Cells wear out and cannot function with aging

 Connective Tissue/Cross-Link Theory

 o With aging proteins impede metabolic processes and cause trouble
with getting nutrients to cells and removing cellular waste products

o Nonstochastic Theories
- Based on genetically programmed events caused by cellular damage that
accelerates aging of the organism
 Programmed Theory
o Cells divide until they are no longer able to; this triggers apoptosis or
cell death

 Gene/Biological Clock Theory

o Cells have a genetic programmed aging code

 Neuroendocrine Theory
o Problems with the Hypothalamus-Pituitary-Endocrine Gland
Feedback System causes disease; increased insulin growth factor
increases aging

 Immunological Theory
o Aging is due to faulty immunological function which is linked to
general well being

 NURSING THEORIES OF AGING

o Functional Consequences Theory
- Environmental and biopsychosocial consequences impact functioning. Nursing’s role
is to minimize age-associated disability in order to enhance safety and quality of living

o Theory of Thriving
- Failure to thrive results from a discord between the individual and his or her
environment or relationships. Nurses identify and modify factors that contribute to
disharmony among these elements
ELECTIVE 2
ASSESSMENT OF OLDER ADULT

FUNCTIONAL ASSESSMENT
To identify an older person’s ability to perform
◦ Self-care
◦ Self-maintenance
◦ Physical activities

TWO ASSESSMENT APPROACHES IN FUNCTIONAL ASSESSMENT

Ask questions about ABILITY

Observe ABILITY through evaluation of task completion

DISABILITY
The impact that health problems have on an individual’s ability to perform tasks, roles, and activities

Measured by asking questions about the performance of ADL’s and instrumental ADL’s
PHYSICAL ASSESSMENT
Based on technical competence, knowledge of the normal changes, and diseases associated with
aging.

ASSESSMENT OF THE SYSTEMS

 CIRCULATORY FUNCTIONS
o Age-related changes in the heart muscle & blood vessels result in overall decreased cardiac
function
o Results to diminished circulatory functions with limited physical activities
 Factors Affecting Circulatory Function
 limited exercise and physical activities
 lifestyle
 smoking
 consumption of alcohol
 disease of the circulatory system
 Assessment
 Family history
 Current problems (chest pain; discomfort) with exertion
 Current diagnoses
 History of medications (prescription, OTC, herbals)
 Source of stress
 Adherence to current medical regimen
 Physical examination
o Blood pressure
o Chest sounds
o Pulse rate
 Stress test
 Blood & serum tests
 ECG’s & echocardiogram

 RESPIRATORY FUNCTIONS
o Age-related changes to bones, muscles, lung tissue, and respiratory fluids contribute to
respiratory difficulties
  Factors Affecting Respiratory Function
 Disease
 Injury
 Restriction in mobility
 Extended bed rest
 Assessment
 Current medications (prescription, OTC, or herbals)
 Smoking behavior
 Exposure to environmental pollutants
 Difficulties in breathing
 Signs of decreased energy levels
 Coughing and production of excessive sputum
 Observe posture and breathlessness
 Auscultate chest sounds
 Blood & pulmonary function tests
 Chest x-rays
 Sputum analysis

 GASTROINTESTINAL FUNCTION
o Age-related changes in the gastrointestinal system are not dramatic and may not be noticed
 Factors Affecting Gastrointestinal Function
 Decreased peristalsis (constipation)
 Reduced gastric acid secretion
 Lack of dietary fiber
 Low levels of physical activity
 Lack of fluids
 Chronic constipation resulting to fecal impaction, incontinence and delirium
 Assessment
 Ask about usual diet
 Appetite and the changes
 Occurrence of nausea, vomiting, indigestion, or other stomach discomforts
 Bowel functions (constipation & diarrhea)
o Exercise, diet, fluid intake
o Medications (prescription, OTC, herbal)
 Oral health
o Observe condition of tongue, teeth, and gums
o Check dentures

 GENITOURINARY FUNCTION
o Age-related changes in the genitourinary system along with age-related diseases can have a
major impact on everyday life
 Factors Affecting Genitourinary Function
 weak bladder muscle resulting to decreased bladder capacity
 Infection
 Childbirth & gynecologic surgery (incontinence)
 Enlarged prostate
 Chronic renal failure
 Assessment
 History of previous or current difficulties related to frequency & voluntary flow
of urine either day or night
 Identify type of incontinence: stress, urge, functional or overflow
 Fluid intake
 Caffeine and alcohol intake (affects bladder tone)
 Observe skin (dehydration)
 Medication use (prescription, OTC, herbals)
 Diagnostic tests
o Urinalysis (blood, bacteria, or ketones)
o Ultrasonography

 SEXUAL FUNCTION
o Age does not change the drive for sexual activity or sexual relationship
 Factors Affecting Sexual Function
 Lack of partner
  Medication use (prescription, OTC, herbals)
 Decrease in speed & duration of erection (males)
 Decreased vaginal lubrication (females)
 Chronic illnesses (osteoarthritis)
 Diminished positive self-image
 Lack of privacy
 Assessment
 Ask about sexual activity

 NEUROLOGICAL FUNCTION
o It affects all other body systems and usually involve decline in reaction time, kinetic & body
balance and sleep disturbances
 Factors Affecting Neurological Function
 Diseases (Alzheimer’s, Parkinson’s, Dementia)
 Stroke
 Assessment
 Medications
 Diagnosis (history & family history of stroke
 Observe & ask about previous & current impairment in:
Speech Orientation
Balance Expression
Energy level Sensation
Swallowing Memory
Motor function
 Occurrence of sleep disturbance, tremors, & seizures

 MUSCULOSKELETAL FUNCTION
o Several age-related changes occur in the musculoskeletal system & lead to decreased
muscle tone, strength, and endurance
 Factors Affecting Musculoskeletal Function
 Stiffening of connective tissues and erosion of articular surfaces of joint
 Decline in hormone production
 Diet
 Disorders (osteoarthritis & osteoporosis)
 Accidents
 Assessment
 History of musculoskeletal illnesses (OA, sore joints), injury, or surgery
 Observe for posture, stance, & walking
 Use of assistive devices
 Observe for body language & facial expressions
 Diagnostic test
o Up & Go Test
o Bone Density Test

 SENSORY FUNCTION
o Age-related & disease-related changes in sensory function can have profound effects on their
day to day functioning
 Factors Affecting Sensory Function
 Problems in vision & hearing
o Presbyopia – inefficient visual accommodation
o Presbycusis – progressive hearing loss
 Assessment
 Assess for reading capacity
 Observe for difficulty and accuracy
 Use of magnification aids
 Ask about any hearing problems
 Observe for appropriate responses
 Assess hearing devices
 Ask for any medical condition
 Medications (for side effects)
 Smoking

 INTEGUMENTARY FUNCTION
 o Age-related changes to the skin include loss of elasticity, slower regeneration of cells,
diminished gland secretion, reduced blood supply, and loss of fat
 Factors Affecting Integumentary Function
 Decreased mobility and extended bed rest
 Skin dryness and itching
 Assessment
 Inspection of the skin (color, hydration, circulation, & intactness)
 Ask for any skin injury and treatment
 Ask for any history of diseases or infection
 Assess nutritional status & body weight
 Assess for loss of sensation

 ENDOCRINE AND METABOLIC FUNCTION

o Age-related changes in endocrine function include decreased hormone secretion and
breakdown of metabolites
 Factors Affecting Endocrine And Metabolic Function
 Disease or illness (Diabetes Mellitus)
 Assessment
 Family history
 Changes in weight and appetite
 Fatigue
 Increased thirst and fluid intake
 Vision problems
 Slow wound healing
 Headaches
 Gastrointestinal problems
 Palpate for nodules at the neck (thyroid problems)
 Assess for hyperthyroidism:
o Observe for occurrence of nervousness
o Heat intolerance
o Weight loss
o Tremors
o Palpitations
 Assess for hypothyroidism:
o Skin changes
o Fluid retention
o Fatigue
o Forgetfulness
o Constipation
o Cold sensitivity

 HEMATOLOGIC & IMMUNE FUNCTION

o Age-related changes in the hematologic function involves decrease in blood cellular
components
 Factors Affecting Hematologic & Immune Function
 Anemia (decreased hemoglobin level)
o Iron deficiency
 Infections
 Assessment
 Observe for skin color, quality of skin, and nail beds
 Assess diet (iron-deficiency)
 Diagnostic test: CBC
 Ask about vaccinations (flu, pneumonia)
 Ask about recent & current infection
 Ask about sexual activity (STD’s)

 COGNITIVE ASSESSMENT
o Varies among older adults and are difficult to separate from other co-morbidities, other age-
related changes, the side effects of medication, and changes in intellectual activity.
o Cognition is usually understood in relation to:
 Qualities of attention
 Memory
  Language
 Visuospatial skills
 Executive capacity
o Cognitive Assessment Tools
 Mini Mental State Exam (MMSE)
 Used to differentiate organic from functional disorders
 It measures:
 Orientation
 Registration
 Attention & calculation
 Short-term recall
 Language
 Visuospatial function
 Mini-Cog
 Used to assist nurses in early detection of cognitive problems

o COMMON COGNITIVE DISORDER

 Alzheimer’s Disease
 Most common form of dementia leading to a permanent decline in cognitive function
 Assessment
o Emphasize individualization
 Ask for previous preferences of care directly from the client
or family members
o Social ability

 PSYCHOLOGICAL ASSESSMENT
o presents a wide continuum from positive mental health to mental health problem
o Two areas of Psychological Assessment
 Quality of life – positive mental health
 encompasses all areas of everyday living
 synonymous with successful aging
 Quality of life among older adults is highly individualistic, subjective, and
multidimensional.
 Depression – mental health problem

o What Comprises Successful Aging?

 Physical health
 Independence
 Functional ability
 Longevity
 Engagement in social life
 Self-mastery
 Optimism
 Personal meaning of life
 Attainment of goals

o DEPRESSION
 it is often associated with cognitive limitations
 Clinical depression is the most common mental health problem among older
adults & it often goes undetected
 Consequences of clinical depression can be serious & induce suicidal
ideations & suicide attempts
 Most Common Causes of Depression
o Widowhood
o Loss of independence
 Signs Of Depression
o Sadness
o Lack of enjoyment
o Significant weight loss
o Sleep disturbance
o Restlessness
o Fatigue
o Feelings of worthlessness
o Impaired ability to think clearly or concentrate
 o Suicide ideation or attempts
 Clinical depression may be chronic or have a shorter duration, and it is not the same
as experiencing temporary feelings of unhappiness, confused thinking, and
somatic complaints.

 SOCIAL ASSESSMENT
o social functioning affects health and disease outcomes & health status affects the ability to
socialize and interact with others
o as people age, they may find their social networks become smaller
o Collect information on the presence of a social network
o Interaction between the older adult and family, friends, neighbors, and community
 Nursing Assessment:
 Identification of social network and social support

 SPIRITUAL ASSESSMENT
o integral part of comprehensive assessment & provides a basis for an individualized plan of
care
o religiosity and spirituality are not synonymous
 Religious belief may foster spirituality; spirituality may not be specific to a religious
belief.
o Guidelines for Spiritual Assessment
 1. The concept of God or deity.
 2. Personal source of strength and hope.
 3. Significance of religious practices and rituals.
 4. Perceived relationship between spiritual belief and health.

 OBESITY
o became a major health problem and associated with chronic diseases and disability
o it causes adverse effects when paired with other organ’s diseases
o Nursing Assessment:
 Assess for overweight and obesity (history of weight change)
 Diet