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GERONTOLOGY NURSING

A. Principles of assessment of the


Elderly

ASSESSMENT OF THE ELDERLY

1.
Physical,
psychological,
and
socioeconomic factors interact in complex
Old age is not synonymous to disease. ways to influence the health and
functional status of the older person.
It is a developmental process.

Decreased efficiency of homeostatic


mechanisms.

2. Functional abilities should be a central


focus of the comprehensive evaluation .

Altered presentation of and response

Physical Examination results

Complex nature of causes of medical

to specific diseases.

conditions.

Health perception of the elderly.

Cultural influences.

Family influences.

Socioeconomic

and

environmental

factors.

Cornerstone of gerontological nursing

Goal conduct a systematic and


integrated assessment

Assessment

can

challenging to nurses

be

lengthy

Laboratory findings
Medical Diagnosis
Nursing Diagnosis

Allow rest period between parts of

the physical
fatigue.

assessment

Provide

Maintain absolute privacy.

Be patient, relaxed, and unhurried

Be alert to signs of increasing

fatigue

B. General considerations in Physical


Assessment

to

comfortable

avoid

Conduct the assessment during the

patients peak energy time

Provide an environment that gives

the older adult the opportunity to


demonstrate functional abilities

room

temperature setting , close to theGeriatric Care Management


restroom.

B. General considerations in Physical


Assessment

Minimize noise and distraction.

Allow sufficient time for client to

respond to directions and to change


position.

Conduct exam in an area with

ample
space
to
supportive devices.

accommodate

B. General considerations in Physical


Assessment

Aims to promote the autonomy of

older individuals to the greatest extent

Functional

status

of

the

older

person is characterized by the gradual


decrease in organ function that
accompany
normal aging and the
more rapid decline associated with
acute and chronic illness.

Geriatric Assessment is a

multidimensional interdisciplinary
diagnostic process intended to
determine a frail elderly persons
medical,
psychosocial,
and
functional
capabilities
and
problems in order to develop an
overall plan for treatment and long
term follow up.

Geriatric Assessment Goals


Geriatric Assessment

Extends

beyond

the

traditional evaluation of older


persons
health
to
include
assessment of;

Components:

Standard

medical

history

and PE

systematic

Improve

process

of

care-

diagnostic accuracy

Optimize medical treatment

Improve medical outcomes

Improve function and quality

of life
search

for

Optimize living location

Reduce unnecessary service

specific
conditions that are common
among older person

Comprehensive Geriatric Assessment

use

Arrange

management

long-term

case

Cost of care

Goal

Highest priority:

Prevention

performance

of

the diagnostic process

and clinical decision making

Screen

for

preventable

diseases

Screen

for

functional

impairments that may result in


physical disability and amenable to
intervention

Components of CGA

1. Medical Assessment

problem list

co morbid conditions and


disease severity

nutritional status

Activity / Exercise Status

Gait and balance

of decline in the

independent
ADLs

Drives

medication review

2. Assessment of Functioning

Basic ADL

IADL

AADL

development

and

implementation of care plan


after
assessment
and
diagnosis

3. Psychological Assessment

Mental

status

Cognitive

procedures
necessary.

testing

Mood / depression testing

include labs

most

and ancillary
that

beneficial

to

are

frail

elderly

medical,psychological,functi
onal, nutritional problem
(chronic
illness,dementia,depression,
disabilities and malnutrition)

4. Social Assessment

informal support needs and


assets

60 yrs and above w/ geria


syndromes

financial assessment

care resource ability

5.

Assessment

home safety

transportation

Environmental

Geriatric Syndromes(5 Is)

Immobility

Instability

1st Step: Screening


Impaired

memory

Iatrogenic disorders

Impaction / Incontinence

Outcome

Identification of the overall

health conditions of the older


person and provide a potential
improvement on their quality of
life.

CGA 3 step process

Screening

or

targeting

of

appropriate patients

Assessment

Criteria that are used to

identify older persons likely


benefit or appropriate for CGA;

(impaired vision/hearing)

of

recommendations,
including
physician and patient adherence
with recommendations.

(intellectual)

Implementation

and

development of recommendations

chronological age

functional disability

physical illness

to

geriatric conditions/ syndromes

Core

team:

doctors,

nurse,SW,

Nutritionist,PT/OT,Pharmacist,
Psychiatrist,Audiologist

psychosocial conditions

previous or predicted high health


care utilization

Exclusion Criteria

Those unlikely to benefit:

terminal illness

severe dementia

complete functional dependence

inevitable nursing home placement

too healthy to benefit

2nd Step: Assessment and Devnt of


Recommendation

CGA Approach

Data gathering

Discussion among the team

Development of treatment plan

Implementation

Chief Complaint and Present Illness

Monitoring response

Past and Current Medical Problems

Revision

Family and Social History

It includes chronological narrative

Basic Assessment Models for Elderly:

F- Fluids

A- Aeration

N- Nutrition

C- Communication

A- Activity

P- Pain

E- Elimination

S- Socialization

Geriatric Assessment

Demographic Data

of reason for patient visit.

Review of systems (ROS)

Geriatric Target Conditions

Dementia or delirium

End-of-life care

Falls or mobility disorders

Barthels Index

Functional Independence Measure

Tools for Psychosocial Assessment

Mini-Mental State Examination

(MMSE)

Malnutrition

Pressure ulcers

Urinary incontinence

ASSESSMENT TOOLS
Geriatric Assessment Tools

are

standardized

means

of

obtaining information as part of a


comprehensive assessment visit.

Tools for Functional Assessment

Katz Index of Activities of Daily

Living

Portable

Mental

Questionnaire (SPMSQ)

Short

Scale for Instrumental Activities of

Daily Living (IADL)

Status

Geriatric Depression Scale or Mood

Assessment

Scale

for

Instrumental

Activities of Daily Living (IADL)

Blessed Dementia Rating Scale

refer the ability to maintain an


independent household.

The Set Test

Michigan Alcoholism Screening Test

Mnemonics

SCUM

or

SHAFT

(MAST)

The Burden Interview

Nowotny Hope Scale

Tools

for

Functional

Assessment

Katz Index of Activities of

an inventory of a clients degree of


independence in bathing, dressing,
toileting, transfer out of bed,
continence and feeding.

Functional Independence

Measure

Daily Living (self-care task)

an evaluation based on 1-100


scale of a clients self care
abilities and degree of mobility,
commonly used in rehabilitation
center.

Barthels Index

Mnemonics - BATTED or DEATH

Psychosocial Assessment tool

Mini-Mental

State

Examination (MMSE):

test of cognitive ability that


evaluates
the
clients
orientation, attention, and recall
and ability to understand and
use language and reproduce
geometric diagram.

FINDINGS:

Short

Portable

Mental

Status Questionnaire (SPMSQ)

score greater than or equal to 25


points (out of 30) indicates a normal
cognition. Below this, scores can
indicate severe (9 points), moderate
(10-20 points) or mild (21-24 points)
cognitive impairment.
The raw score may also need to be

test of cognitive ability that


measures
orientation,
knowledge of current events,
and ability to perform simple
arithmetic calculation.

Question Response

corrected for educational attainment


and age.
1. What are the date, month, and year?

o
o

maximal score of 30 points can never

2. What is the day of the week?


3. What is the name of this place?

rule out dementia.

4. What is your phone number?


Low

to

very

low

scores

correlate

closely with the presence of dementia

5. How old are you?


6. When were you born?
7. Who is the current president?
8. Who was the president before him?
9. What was your mother's maiden name?
10. Can you count backward from 20 by
3's?
SCORING:*
0-2 errors: normal mental functioning
3-4 errors: mild cognitive impairment
5-7
errors:
impairment
8 or more
impairment

moderate
errors:

severe

cognitive
cognitive

*One more error is allowed in the scoring


if a patient has had a grade school
education or less.
*One less error is allowed if the patient
has had education beyond the high
school level.

Geriatric Depression Scale or

Mood Assessment Scale:

Use to screen for and determine


severity of depression.

Blessed Dementia Rating

Scale:

evaluation of the clients ability


to
perform
activities
(e.g.
handling
small
amount
of
money, finding the way around
familiar
streets,
eating,
dressing, toileting)

The Set Test

test of cognitive ability in which the


client is asked to name as many
colors, animals, fruits, and towns
as possible up to a maximum of 10
per category

Michigan

Alcoholism

Screening Test (MAST)

diagnostic test in which the client is


asked question about the effect
that drinking has or has had on his
everyday life.

The Burden Interview

used to estimate the degree of


stress that the caregiver of a
spouse is experiencing.

used to measure the clients

Cognitive Function

SOCIAL ASSESSMENT
Should include availability of help in
case of emergency.

o
o

Advanced directives.

Availability of a personal support


system
Need for a caregiver.

Occupation, retirement and income


level

Nowotny Hope Scale

capabilities
for
dealing
constructively with a stressful
events.

Economic status.

Participation in economic assistance


program

Living arrangements

motivation and adherence to medical


recommendations

Other Domains to be assessed of the


Geriatric

Those taking long than 10

seconds to complete this tasks are


at increased risk for falls.

Nutrition

10

19

seconds

is

considered freely mobile.


Sleep

Sexual activity

Recreational activity

Security

Injury Risk

Review of Systems

MOBILITY
AND
BALANCE
ASSESSEMENT FOR FALLS

20 29 seconds variable

mobility.

>30 seconds dependent on

balance

Abnormalities are : path

deviation, diminished step height


or length, trips, slips, near-falls,
and difficulty turning.

RISK

Get-up and Go Test

The task of rising from an

armless chair, walking 10ft, turn,


walk back and sit down

Health Care Delivery System

depend on social security as main


source of income

Introduction

Meeting the needs of a rapidly growing

Will compare models of healthcare to

older adult population is challenging


worldwide

provide insights into how to meet


these challenges

Health Care System an organized

Health

plan of health services (Miller- Keane,


1987)
Care

Delivery

System

rendering health care services to the


people (Williams-Tungpalan, 1981)

Social Security

Federal old-age pension program

Mandatory

Fewer

participation

through

payroll contributions
benefits

than

many

industrialized nations

75% of poor elderly are women who

Delayed retirement credit (DRC)

other

Women are 60% of recipients at age


65

Medicare

Through Social Security Act to provide


some kind of universal health care
insurance for elderly and those with
ESRD

Part A: Hospital insurance

Medicare (contd)

Inpatient care

Part C:

Skilled nursing facility

HMO (health maintenance org)

Hospice care

PPO (preferred provider org)

Home health

Part

B:

Supplemental

medical

insurance

Lab
Home health
Doctor visits
Some outpatient therapies
Mental health services
Outpatient hospital services
Assistive Devices
Some

medications (hormonal tx,

chemotx)

Part D:

Prescription drug plan

Long-Term Care

Home Care

Assisted Living

Does now cover some screenings

Medicaid

Financed

government

Philippine Health Care System

Administered by state Coverage and

Universal Health Care for all Filipinos

Kalusugang Pangkalahatan

by

state

and

federal

eligibility differ from state to state

Three types of protection

Health

insurance for low-income

families and people with disabilities

LTC

for

older

Americans

and

persons with disabilities

Supplemental

coverage for low-

income Medicare beneficiaries for


services not covered by Medicare

LTC

insurance

available

expensive

Settings for Care in the U.S.

Acute Care

but

very

Approach:
General
promotion.
Protection
specific illnesses.

PCB1

to expand the no of services


included in the Primary Health CarePRIMARY LEVEL
(Philhealth mem)
FACILITIES

Enhance

incentives

for

Ensure

complete

and

Rural health units,

timely

Puericulture centers

reporting of health data

PCB 1 inclusion

o Primary Preventive Services


o Diagnostic Examinations
o Drugs and Medicines
Three levels of Health Care

Tertiary

Secondary

Primary

Primary Care

OF HEALTH CARE

PCB

providers

health
against

Private clinics,;

Community

hospitals

and

health

technological

Secondary Care
Health Care Settings
Goal: To alleviate disease
prevent further disability.

and

Hospital Schools

SECONDARY LEVEL OF HEALTH CARE


FACILITIES

Industrial Clinics

Managed care organizations

Community nursing centers

Rural primary care hospitals

Smaller,

non-departmentalized

hospitals including
regional hospitals.

Services

offered

emergency

to

patients

and

with

symptomatic stages of disease, which


require
moderately
specialized
knowledge and technical resources for
adequate treatment.

and

sophisticated services offered by


medical centers and large hospitals.
These are the specialized national
hospitals.

centers

Highly

Tertiary Care
Approach:Restorative
and
rehabilitative activities to attain
optimal level of functioning.

TERTIARY LEVEL OF HEALTH CARE


FACILITIES

Extended-care facilities

Home health care agencies

Nursing Facility

Hospices

Nursing Center

Out-patient settings

Health Care Team Members


Health
care
is
delivered
by
a
multidisciplinary team, all working
together. Examples include:

Physician (MD)

Nurse (RN, LP/VN)

Nurse Assistant (CAN)

Registered Dietician (RD)

CARE OF THE OLDER ADULTS

Nursing Home :
= is the dominant setting in which
long term care is provided for people
who require regular or continuous
skilled nursing care.

Other Names:

Health Care Centers

Resisting

to

stereotype

patients

because of their age.

ACUTE CARE SETTING

Hospital setting most admission

Hospital based practice requires all of

on the hospital comprise people aged


65 years old.

Create safe and caring environment

Environment management

that facilitates independence.

ACUTE CARE SETTING

the basic skills the nurse posses.

Acute care involves brief contact with

Specialized and efficient approach to

Need for this setting still

relevant for acute or emergency


cases.

a large number of patients.

elderly management.

CHF and other CV emergencies

Not the choice of health care delivery

Stroke

High incidence of functional decline

system anymore.

and loss of independence of


patients because of the setting

the

Challenges in giving care to older


adults

Establishing trusting relationship over


a short period of time.

Dealing with problems secondary to


relocation stress or medications.

Chemotherapy

HHC = consist of multiple health


and social services delivered to
recovering,
chronically
ill,
or
disabled individuals of all ages in
their place of residence.

Surgeries
Other acute conditions

They are covered by Medicare,


Medicaid, Private Insurance, HMOs,
private pay.

Goal of Acute Care Facility:


Benefits of Home Care
Home Care and Hospice

They are community based service


providers who are challenge to
develop affordable and appropriate
programs to assist older adults to
remain
in
the
home
while
maintaining a good quality of life.

Changes in technology, equipment is

Family, friends, clients can be taught

Community-Based Services

2 Categories of Community Service:

Home Health Care

to

manage,

less

to manage treatment like : enteral


feeding, central line, pain control,
antibiotic therapy, urinary catheter
with minimum assistance.

Nurses in this area must have


sharp
assessment
skills
and
knowledge
of
normal
aging
changes, chronic illness, and the
effects of illness and treatments on
older adults.

smaller, easier
expensive.

Less expensive than hospitalization in


most cases.

There are sound medical and humane

reasons for treatment to take place in


a persons home.

Nasocomial infection are minimized.

Hospice and Palliative Care

not

Goals:
It

provides

It

is

care
ill

and

services

persons

special

kind

and

of

to

their

medically

directed compassionate care for dying


individuals and their families.
The care is designed to address the
physical, emotional, psychological and
spiritual needs of dying persons, to
provide support services for their
families during both the dying and
bereavement processes.

GOAL of Hospice: To
comfort care NOT cure.

provide

WHY Hospice?

Palliative Care active total care of


clients
whose
disease
is
responsive to curative treatment.

Hospice

terminally
families.

to stop pursuing aggressive medical


treatment.

When a person or family have decided

Preferred by individuals with incurable/


irreversible disease
respond to treatment.

that

do

not

Achievement

It affirms life and regards dying as a

of

the

best

possible

quality of life for clients and families.

normal process.

It emphasis relief of pain and other

Offers a support system to help the

distressing symptoms

family cope during the clients illness


and in their own bereavement.

Qualities of a Gerontology Nurse

o
o
o
o

services, day care centers, & hospice.

Clear understanding of normal and


abnormal aging.
Strong assessment skills

(subtle

changes=

Need for adequate number of qualified

Tendency to have a one size fits

understanding

Lack of available facilities that are

Persons living in the nursing facility is

of

rehabilitation principles.

Excellent communication skills

Sensitivity and patience =treating

Communication
Senses and Communication

o
o

Health services that encompass the

Less expensive and more conducive to

care

outside

the

functional independence compared to


the hospital setting.

More common setting for the elderly


patient.

Vision 70% of all sensory info comes


through the eyes

LONG TERM CARE SETTINGS

of

necessary for health promotion and


disease prevention.

called- resident.

the elderly with dignity and respect

continuum
hospital.

and professional nursing staff.

all approach in the management of


the elderly.

impending

serious problems).
Keen

Includes nursing homes, home health

Hearing provides source of info as


well as interpretation of meaning

Pitch high/low
Timber quality

Touch may be substitute for sight

Smell & Taste convey meaning and

Movement allows receipt of info from

Cataracts

Painless progressive vision loss 70%

Increasing lens opacity causes


spraying of light and blurriness around
edges of objects

trigger feelings

environment, nonverbal
communication

Speech- primary form of

Note that disability can affect ability to

communication with environment

convey or receive info

The Role of the Brain in


Communication

Cortex responsible for higher

Thalamus relay station

Forebrain interprets information

thought and function; contains all


sensory and motor information

Common Visual Diseases

of Americans develop after age 75

Cause: hereditary, advancing age

Corrective cataract surgery

Glaucoma

Macular Degeneration

Increase of intraocular pressure which

Asymptomatic until late in disease

Early detection important

Screening identifies 90% of patients

causes damage to optic nerve which


can lead to blindness

with increased pressure

Most common cause of legal

Progressive degeneration of macula

blindness in people over 50

and loss of central vision

Starts in one eye and moves to other

Early diagnosis over 50 should have

eye in 5 years

eye exam every 2 years


Treat with eye drops to prevent vision
loss

Prostaglandin, Betar blockers,


alpha agonist, CAI

Diabetic Retinopathy

Visual complication of elevated blood

Accounts for 7% of blindness in US

Early detection and treatment of

Annual eye exams

sugar, which causes microaneurysms


in retinal capillaries

diabetics to prevent substantial vision


loss

Special Considerations:

medications or poisons

Blindness

Position where patient might Special Considerations:

be able to see you.

Explain procedures before

doing them.

Ototoxicity hearing loss due to

If patient has glasses make

sure they are wearing them.

Never pull blind patient.

Walk at their side and hold

Deafness

Never assume the patient is

deaf.

If patient is wearing a

hearing aid, make sure it is on.

Determine if the patient can

lip-read.

their arm.

Let them know about

obstacles.

Never yell at a blind patient.

Pathological Processes Associated


with Hearing Loss

Presbycusis difficulty with high

Tinnitus persistent ringing,

pitched tones and speech


discrimination

buzzing, or roaring

Note writing.

Hearing impairment can lead to

social isolation, perception of others


of cognitive decline and depression

Pathological Changes in Speech and


Language

Dysarthria lose ability to


articulate, brain lesions main cause

answer you with a simple "yes" or


"no."

When possible, give clear choices

Visual prompts are also helpful,

Expressive: unable to

Receptive: unable to

comprehend

for possible answers, but do not


give them too many choices.

when you can give them.

Break down instructions into small

Allow time for the person with

produce language

Ask questions in a way they can

5. When you give instructions:

Aphasia

Verbal apraxia speech disorder,


impaired initiation, coordination
and sequencing of muscle
movements which execute speech,
caused by damage to parietal lobe

Communicating with Aphasic


1. Keep distractions and noise down:
2. Talk to people who have aphasia in
adult language.
3. If they can not understand you, do not
shout.
4. When you ask questions:

and simple steps.

aphasia to understand. If the


patient becomes frustrated,
consider changing to another
activity.

6. Encourage the person with aphasia to


use other ways to communicate. Some
are:

Pointing

Hand gestures

Movement Disorders in Older Adults

Activities of Daily Living basic

Instrumental Activities of Daily


Living more complex tasks such
as handling finances, managing
meds, preparing meals

Drawings

7. It may help the person with aphasia


and their caregivers to make a book with
pictures or words about common topics or
people so that they can communicate
better.

8. Always try to keep the person with


aphasia involved in conversations. Check
with them to make sure they understand.
9. Do not try to correct the person with
aphasia if they remember something
incorrectly.
10. Begin to take the person with aphasia
out more, as they become more
confident.
11. When leaving someone with speech
problems alone, make sure they have an
ID card that:

Has information on how to contact

Explains their speech problem and

family members or caregivers

how best to communicate with


them

Consider joining support groups for


people with aphasia and their
families.

tasks such as eating, bathing,


toileting, grooming

As seen in Parkinsons Disease


tremor, rigidity, stiffness, slowness
of movement, postural instability,
and/or impaired balance and
coordination

Common Pathological Cognitive and


Psychological Changes in Older
Adults

Delirium: sudden onset, lasting

Dementia: insidious onset, lasting

days to months, reversible, recent


and remote memory impaired

from months to years, irreversible


but can be slowed with use of
meds, progressive loss of memory
with recent affected prior to remote

Allow extra time

Avoid distractions

Sadness

Sit face to face

Lack of interest or pleasure in

Maintain eye contact

Speak slowly and clearly

Use simple, short words and

Depression

Very serious; Characterized by at


least 5 of the following symptoms:

activities they once enjoyed

Significant weight loss or gain

Marked decrease or increase

in sleep

Psychomotor agitation or

sentences

Stick to one topic at a time

Simplify and write down your

retardation

Fatigue

Feelings of worthlessness or

inappropriate guilt

Impaired ability to think or

concentrate

instructions

Use charts, models and

pictures

Frequently summarize the

most important points

Recurrent thoughts of death,

including suicide ideation or


attempts

Communication Tips

Summary

Communication in Healthcare

Normal aging changes may result

in a decreased ability of the older


adult to communicate effectively.

These changes may affect both the

Nurses should be mindful of and

ability to receive and transmit


information.

sensitive to these changes when


planning care and teaching.

Instrumental communication:
necessary behavior for assessing
and solving problems

Affective communication: focuses


on how the HCP is caring about the
person and his or her feelings and
emotions

Communicating with the Older Adult


Basic principles for communication

Therapeutic Communication

A core skill for nurses

An exchange of information

Augmentive and alternative

(Satir, 1976):

o Invite: Im interested, openended questions

o Arrange environment: make it

conducive to communication, eye


to eye contact

communication system (AAC) = all


forms of communication that
enhance or supplement speech and
writing; can enhance or replace
conventional forms of expression

Hearing aids

Picture boards

Synthesized

(computer-generated) and
digitalized (recorded) speech

o Maximize understanding: be a good


listener

o Maximize communication:

consider the patients health


literacy level

o Follow- through: forms trust