GERIATRICS

Goal of Geriatric Nursing

• “Promoting, and maintaining functional status and helping older adult to
identify and use their strength to achieve optimal independent

DEFINITION OF TERMS
• Geriatrics - the study of old age , include the physiology, pathology, diagnosis,
and management of the diseases of older adults
• Gerontology - study of aging process, draws from psychological, biological,
sociologic science
• Geriatric Nursing - is the field of nursing that specializes in the care of the
elderly

DEFINITION OF TERMS
• Ageism- bias against older people w/o considering their functional status
• Intrinsic aging- refers to those changes caused by normal aging process
• Extrinsic aging- refers to aging that results from influences outside the person

CAUSE OF DEATHS IN 65 YRS AND ABOVE

• Heart diseases
• Neoplasms
• Cerebrovascular diseases
• COPD
• Pneumonia and influeza
• DM
• Accidents
• Alzheimer’s diseases
• Renal problems

BIOLOGIC THEORIES OF AGING

• Immune system theory
• Cross-linking theory
• Free radical theory
• Stress theory (wear and tear)
• Genetics theory
• Neuroendocrine theories

IMMUNE SYSTEM THEORY

• The two primary immune organs, the thymus and bone marrow, are affected by
the aging process, which contributes to a decline in T-cell production and stem cell
efficiency
• Increase of infections, autoimmune disease, and cancer with aging

CROSS-LINKING THEORY
• a chemical reaction that binds glucose to protein, which causes abnormal
division of DNA, interfering with normal cell functioning and intracellular transport over a
lifetime
• Eventually causes tissue and organ failure

FREE RADICAL THEORY

• Molecules that are highly reactive as a result of oxygen metabolism in the body
• Over time, cause physical decline by damaging proteins, enzymes and DNA
• Beta-carotene and Vitamins C and E are naturally occurring anti-oxidants that
counteract the free radicals

STRESS THEORY (wear and tear)

• The body, like any machine, will eventually “wear out” secondary to repetitive
usage, damage and stress
• While this theory is seen as having some merit, individuals react differently to
stress (positive and negative), causing controversy over the concept

GENETICS THEORY
• Pre-programmed life expectancy. Cells can only divide a specific number of
times
• Life expectancies among family members is similar, eg. If the parents died over
the age of 80, the children are more likely to live to that age

NEUROENDOCRINE THEORIES
• Anterior pituitary hormones are thought to contribute to the aging process
• An imbalance of certain chemicals in the brain may contribute to altered cell
division within the body

NORMAL AGE –RELATED CHANGES

Intrinsic aging – changes cause by normal aging process
Extrinsic aging – influences outside the person) air pollution, illness and disease that
may hasten the aging process
1. body’s ability to maintain homeostasis become increasingly diminished with cellular
aging and organ system
2. cells become less able to replace and accumulate as pigment called lipofuscin
3. degradation of elastin and collagen causes connective tissue to become stiffer and
less elastic

Different Aspect of Aging :

• Physical aspect of aging
• Psychosocial aspect of aging
• Cognitive aspect of aging
• Environmental aspect
• Pharmacological aspect

PHYSICAL CHANGES OF AGING

PSYCHOLOGICAL ASPECT OF AGING
• Ageism – prejudice or discrimination against older people
• Comprises of the ff:
1. Stress and coping in the older adult
- positive self-image
- determined by past experiences
2. Developmental theory of aging
- erickson – ego integrity vs despair
- Havighurst
3. sociologic theories of aging

COMMON STRESSORS
1. normal aging changes that impair physical function, activities and appearance
2. disabilities from chronic illness
3. social environmental losses related to loss of income and decrease abilities to
perform previous roles and activities
4. death of significant others
5. lack of social engagement

ERICKSON DEVELOPMENTAL THEORY OF AGING

• ego integrity vs despair
• Achieving ego integrity:
1. accepting one’s lifestyle
2. believing that one’s choice were the best at particular time
3. being in control of one’s life

HAVIGHURST DEVELOPMENTAL THEORY OF AGING

task of older people are the ff:
• 1. adjusting to retirement after a lifetime of employment with possible reduction
of income
• 2. decreases in physical strength and health
• 3. death of spouse
• 4. establishing affiliation with one’s age group
• 5. adapting to new social roles in a flexible way
• 6. establishing satisfactory physical living arrangement

COMBINING THE CONCEPT: ERICKSON AND HAVIGHURST

• 1. maintenance of self-worth
• 2. conflict resolution
• 3. adjustment to the loss of dominant roles
• 4. adjustment to the death of significant others
• 5. environmental adaptation
• 6. maintenance of optimal level of wellness

SOCIOLOGIC THEORIES OF AGING

• Sociologic theories - attempt and predict social interaction and roles that
contribute to the older adult successful adjustment to old age
• Activity theory- life satisfaction in normal aging requires maintaining the active
lifestyle of a middle age
• Continuity theory - successful adjustments to old age requires continuing life
patterns across a lifetime

COGNITIVE ASPECT OF AGING

Affected by the ff:
• 1. sensory impairment
• 2. physiologic health
• 3. environment and psychosocial influences

Comprises by the ff:

• 1. intelligence
• 2. learning
• 3. memory

COGNITIVE ASPECT OF AGING

1. intelligence – decline beginning in midlife (spatial perception and non intellectual
information)
2. learning – decline especially after 7th decade of life
- influences by the ff:
1. motivation
2. speed of performance
3. physical status
3. memory-integral part of learning
1. short-term memory- 5 to 30 secs.
2. recent memory - 1hour to several days
3. long term memory- lifetime

ESSENTIAL COMPONENTS OF MEMORY PROCESS

• 1. acquisition of information
• 2. registration
• 3. retention
• 4. recall
benign senescent forgetfulness – age-related loss that affect the short term and
recent memory

ROLE OF A NURSE
1. supplies mnemonics to enhance recall of related data
2. encourage ongoing learning
3. links new information with familiar information
4. uses visual, auditory and other sensory cues
5. encourage learners to wear prescribed glasses and hearing aids
6. provides glare – free lighting
7. provide quiet non distracting environment
8. sets short term goals with input from the learners
9. keep teaching periods short
10. encourage verbal participation of learners
11. reinforce successful learning in a positive manner

ENVIRONMENTAL ASPECT OF AGING

1. living arrangement option
2. life care plans
3. role of the family
4. community support services
5. home health care
6. safety comfort in the home environment
7. hospice services

LIVING ARRANGEMENT OPTIONS

 Continuing Care Retirement Communities (CCRCs)
 Assisted living facilities
 Skilled nursing facility

ENVIRONMENTAL ASPECTS OF AGING

• Life care plans - a document that assess and evaluates a client’s present, future,
health care and living needs
• Role of family- planning for care and understanding psychosocial issues in adults
must be accomplished w/in the context of the family

ENVIRONMENTAL ASPECTS OF AGING

• Community support services – helps the older person to maintain independence
• Home health care – means to prevent hospitalization
• Safety and comfort in the home – adequate lighting, sharply contrasting colors,
grab bars, anti-slip mat, loose clothing and ill-fitted shoes should be avoided, familiar
settings
PHARMACOLOGIC ASPECT OF AGING
• Altered pharmacokinetics - reduce capacity of the liver and kidney to metabolize
and excrete the medications; lowered efficiency of the circulatory and nervous system in
coping w/ effects of medications

NURSING INTERVENTION
1. Meds removed by renal excretion remain in the body longer- dosages should be
reduced and overdosage and toxicity monitored
2. Meds w/ a narrow safety margin (digitalis) must be administered cautiously
3. A decline in CO may decrease the delivery rate to the target organ or storage tissue
4. The circulatory and CNS are less able to cope w/ effects of certain medications
5. Watch out for idiosyncratic or unusual responses to meds
6. Prolonged medication actions due to slowing metabolism causing increase tissue and
plasma levels
7. Check for drug-drug interactions
8. High fiber diet and use of psyllium (metamucil) or other laxatives may accelerate GIT
transport and reduce absorption of meds
9. Check that patient’s are dependable and religiously taking medications
10. Teach self-administration of medications and request return demo

NURSES ROLE TO IMPROVE COMPLIANCE

1. explain the reaction, side effects and dosage of each medication
2. write out the medication schedule
3. encourage the use of standards containers without safety lids
4. destroy all unused medication
5. review the medication scheduled periodically
6. discourage the use of the OTC medication and herbal medicine without
consulting health professionals
7. encourage the patient to take all the medication, including OTC medication
with him or her regularly when visiting the primary health care provider

PHYSICAL HEALTH PROBLEM

Geriatrics syndrome :
1. impaired mobility
2. dizziness
3. falls and falling
4. urinary incontinence
5. AIDS

COMMON MENTAL PROBLEMS

• Depression
• Delirium
• Dementia

GERIATRIC SYNDROME
• “ frail syndrome”
• frail person are those who are more vulnerable to significant problem and
meeting 1 or more of the ff: condition :
 1. being 85 years of age older
2. being unable to perform ADL
3. suffering from multiple chronic dse

IMPAIRED MOBILITY
• Common cause
• 1. osteoporosis
• 2. osteoarthritis
• 3. CVS
• 4. Parkinson dses.
• 5. DM neuropathy
• Management: encourage them to stay active as possible

DIZZINESS
• true dizziness – sensation of disorientation in relation to position
• Vertigo – spinning sensation

FALL
• common and most preventable source of mortality
• major cause of trauma in elderly

URINARY INCONTINENCE
• common causes:
1. Delirium and dehydration
2. Restricted mobility and restraint
3. Inflammation and infection
4. Pharmaceutical and polyuria

DEPRESSION
• most common affective or mood d/o of old age
• feeling of sadness
• fatigue
• diminished memory and concentration
• feeling of guilt and worthlessness
• sleep disturbance
• suicidal ideation

MANAGEMENT
• Antidepressant
• TCA
• SSRI
• psychosocial approach

DELIRIUM
• “ acute confusion state “
• medical emergency
• common S/Sx -hallucination, fear, delusion, anxiety and paranoia
• Management: nutritional and fluid intake should be supervised, environment
should be calm and quiet, encourage family and friend to touch and talk to patient

DEMENTIA
• to diagnose at least 2 domain of altered function must exist: memory and at least
1 of the ff:
• 1. language
• 2. perception
• 3. visuospatial function
• 4. calculation
• 5. judgement
• 6. abstraction
• 7. problem solving.
is characterized by an uneven, downward decline in mental function .
has 2 types: 1. multi-infarct dementia
2. Alzheimer's disease

ASSESSMENT
I. HEALTH HISTORY AND GERENTOLOGIC FOCUS
A . Assessment of the older adult client is complex
1. Allow sufficient time to conduct a thorough healthy history interview
2. Depending on the client’s stability, the interview may take more than one session

B. PRESENTING PROBLEM
• Assess client systematically depending upon the presenting problem
• Typical presentations of disease may change with age (eg. Client may not exhibit
chest pain with a myocardial infarction)
• The problem is likely to have multiple contributing factors and affect the client’s
functional abilities

C. MENTAL STATUS AND MENTAL HEALTH

• 1. It is important t maintain a baseline for orientation, memory, level of alertness,
and decision-making capabilities
• 2. Assess the client for quality of life issues, mood, affect, and anxiety

D. LIFESTYLE AND FUNCTION

• 1. Often, there is little correlation between diseases and functional abilities
• 2. The functional assessment provides a clearer picture of physical, psychology,
and social health
• 3. Use the client’s own baseline from previous assessments to determine any
changes in function
• 4. Have the client demonstrate function wherever possible (eg. Observe gait and
balance, drinking glass of water, dressing self)

E. MEDICATION USAGE
• 1. Ask for information about all types of medications that the client is taking,
including prescription medications, non-prescription medications (especially analgesics
and laxatives), vitamin supplements, and herbal medications
• 2. Be sure the client understands the purpose, dosage, side effects, and any
special considerations or interactions for all medications
• 3. Discuss the client’s abilities to obtain medications (eg. Renewing
prescriptions, paying for medications)
• 4. Polypharmacy is often present. Average older adult takes 11 prescription
medications per day

F. NUTRITION AND HYDRATION

• 1. Obtain food/ fluid intake profile (either 24 hours or 3 days)
• 2. Determine any difficulties ingesting food/ fluids (chewing, salivation,
swallowing, manual dexterity, tremors)
• 3. Any foods the client is unable to eat (dairy products, sodium, sugar) or foods
the client should eat (potassium- or calcium-rich foods/fluids)
• 4. Taking in adequate amounts of water daily to stay hydrated?
• 5. Ability to afford/purchase/prepare food?

G. PAST MEDICAL HISTORY

1. Inquire about all chronic diseases and conditions. Be aware that the client may not
even consider certain conditions treatable and therefore does not mention them, eg.
Urinary incontinence or pain from arthritis
2. Obtain information about previous illnesses, hospitalizations, and surgeries

DIAGNOSIS
 Physical Examination
• Assess body systems as indicated
• Note physical changes in the older adult

III. Laboratory/Diagnostic Tests

• Laboratory tests as indicated according to symptoms of individual client
• Interpret lab test results with aging changes in mind

ANALYSIS/ NURSING DIAGNOSES FOR OLDER ADULT CLIENTS

A. Activity intolerance
 B. Bowel incontinence, constipation, diarrhea
C. Acute or chronic pain
D. Anxiety or death anxiety
E. Deficient fluid volume
F. Risk for infection
G. Impaired memory
H. Impaired physical mobility
I. Impaired oral mucous membrane
J. Imbalanced nutrition: less or more than body requirements
K. Ineffective airway clearance or breathing pattern, or impaired gas exchange
L. Self-care deficits: feeding, bathing/hygiene, dressing, grooming, toileting
M. Disturbed body image or ineffective role performance
N. Disturbed sensory perception
O. Sexual dysfunction
P. Impaired skin integrity
Q. Disturbed sleep pattern
R. Disturbed thought process
S. Ineffective tissue perfusion
T. Impaired urinary elimination
U. Deficient diversional activity
V. Wandering
W. Impaired social interaction
X. Risk for other-directed violence
Y. Risk for falls or injury
Z. Relocation stress syndrome
AA. Impaired home maintenance

PLANNING AND IMPLEMENTATION

Goals : Client will maintain
A. Maximum functional independence
B. Normal bowel and bladder elimination patterns
C. Sufficient communication skills
D. Positive self-concept
E. Freedom from injury and infection
F. Optimal cognitive functioning
G. Adequate nutritional status and fluid balance
H. A restful sleep pattern
I. Social contacts and interpersonal needs
J. Treatment regimens are prescribed

INTERVENTIONS
PHARMACOTHERAPY IN THE OLDER ADULT
1. General Information
• Decreased body weight, dehydration, alterations in fat to muscle ratio, and
slowed organ functioning may cause accumulation of a drug in the body due to higher
concentrations in the tissues and slowed metabolism and excretion of the drug
• Multiple chronic diseases affecting older adults may also cause changes in the
metabolism and excretion of medications
• Medication errors among older community-dwelling adults are estimated to be
20-50%
• Drug-drug interactions are increased secondary to older adults often having more
than one prescribing health care provider

2. NURSING CARE
• Conduct a “brown bag” evaluation to assess all prescription, over-the-counter,
and herbal medications the client may be taking
• Assess the client’s understanding of the reasons for the drug’s therapy
• Assess the client’s vision, memory, judgement, reading level, and motivation to
determine ability to self-medicate
• Provide instructions in large-print, premeasured syringes, memory aids, and daily
drug dose containers to enhance self-medicating abilities
• Check with the pharmacist for any drug-drug interactions if unsure
• Before beginning a medication, obtain baseline vital signs, mental status, vision,
and bowel/ bladder function

• Drug-induced side effects may present as confusion, incontinence, falls or

immobility
• Assess the client’s ability to pay for the prescriptions
• If the client requires assistance in taking medications, teach family members.
Proper techniques for administering oral medications include: position head forward with
neck slightly flexed to facilitate swallowing and avoid risk of aspiration
• If client has swallowing difficulties, obtain liquid forms of oral medications
wherever possible
• Assess client for effectiveness of medications and any adverse reactions

EVALUATION
A. Client performs self-care activities or caregiver provides assistance as needed
B. Client is continent of bowel and bladder; voids in adequate amounts and has regular
bowel movements
C. Client is able to successfully communicate needs and concerns
D. Client makes positive statements about self
E. Client/ caregiver modifies environment to support safety
F. Client is alert, calm, and oriented if possible
G. Skin is intact without pressure ulcers
H. Client eats a nutritionally balanced diet and maintains a stable weight
I. Client maintains friends, social interactions, and sexual function
J. Client describes and adheres to treatment plan

DEATH AND DYING

OVERVIEW OF DEATH AND DYING
• One of the most difficult issues in nursing practice
• Often difficult for nurses to maintain objectivity because of identification and
response to death based on own value system and personal experiences
• Nurses need to take time to analyze their own feelings about death before they
can effectively help others with terminal illness

ASSESSMENT
• A. Physical discomfort
• B. Emotional reaction (withdrawal, anger, acceptance) and stage of dying
• C. Desire to discuss impending death, value of own life
• D. Level of consciousness
• E. Family needs
• F. Stages of dying (Kuber-Ross)

STAGES OF GRIEVING (Kubbler-Ross)

1. Denial – refuses to believe that the loss has occurred
2. Anger – the individual resists the loss and may “act out” feelings.
3. Bargaining – the individual attempts to make a deal in an attempt to postpone the
reality of loss.
4. Depression – feeling of loneliness and withdrawal from others
5. Acceptance – the individual comes to terms with loss, or impending loss,
psychological reactions to loss to the loss cease, and the interaction to other people
resumed

PNEUMONIC: (DABDA)
Stages of beliefs in death
End of life care
Assessment of end of life care beliefs, preferences & practices
 Disclosure or truth telling
 Decision making style
 Symptom management
 Life sustaining treatment expectations
 Desired location of dying

Spiritual or religious practices

 Care of the body after death
 Expression of grief
 Funeral & burial practices
 Mourning practices

End of life care

• Goal setting in palliative care
• Discussing end of life care
 Initiate discussion
 Clarify understanding of medical treatment plan & prognosis
 Identify end of life priorities
 Contribute for the interdisciplinary care plan

SIGNS OF APPROACHING DEATH

• Anorexia
• Decrease urine output
• Patient sleeps more & begins to detach from environment
• Mental confusion
• Audio-visual impairment & incomprehensible speech
• Secretions may accumulate at the back of throat
• Irregular breathing with apnea
• Restlessness
• Initially px feels hot then cold after
• Loss of bladder control

NURSING DIAGNOSES FOR THE DYING CLIENT MAY INCLUDE:

• A. Anxiety F. Impaired mobility
• B. Pain G. Powerlessness
• C. Ineffective coping H. Self-care
• D. Fear I. Social isolation
• E. Anticipatory grieving J. Hopelessness
PLANNING
GOALS:
1. Maintain optimum physical comfort
2. Maintain sense of security
3. Have opportunity to discuss what death means and to progress through stages of
dying
4. Help client accept losses
5. Provide relief from loneliness, fear and depression

MAJOR GOALS FOR THE DYING CLIENTS ARE

• To maintain PHYSIOLOGIC and PSYCHOLOGIC support
• To achieve a dignified and peaceful death
 To maintain personal control

INTERVENTION
• Recognize clients/families have own way of dealing with death and dying
• Support clients/families as they work through dying process
• Accept negative responses from clients/ families
• Encourage clients/families to discuss feelings related to death and dying
• Support staff and seek support for self when dealing with dying client and
grieving family

INTERVENTION
• D – SUPPORTIVE
• A - PROVIDE STRUCTURE AND CONTINUITY
• B – LISTEN AND ENCOURAGE
• D - ALLOW EXPRESSION AND PROVIDE FOR SAFETY
• A - ENCOURAGE PARTICIPATION

NURSING INTERVENTIONS FOR GRIEF AND MOURNING

 Support expression of feelings
 Encourage telling of stories in open ended statements
 Assist mourner to find an outlet
 Assess emotional affect
 Assess for guilt and regrets
 Assess for presence of social support
 Assess for coping skills
 Assess for signs of complicated grief & offer referral

EVALUATION
A. Client has
1. Taken opportunity to discuss feelings about impending death and eventually
acknowledges inevitable outcome
2. Been comfortable and participated in self-care for as long as possible
B. Family discussed feelings about loss of loved one

GRIEF AND LOSS

• Grief is a form of sorrow involving feelings, thoughts, and behaviors
caused by bereavement
• Loss is a universal experience that occurs throughout life span
• Responses to loss are strongly influenced by one’s cultural background
• The grief process involves a sequence of affective, cognitive and psychological
states as a person responds to, and finally accepts a loss.
• LOSS= something valuable is gone
• GRIEF= total response to emotional experience related to loss
• BEREAVEMENT= Subjective response by loved-ones
• MOURNING= behavioral response

OVERVIEW OF GRIEF AND LOSS

A . Response to loss (person, body part, role)
B. Biologic, psychologic, social implications
C. Family system effects
D Mourning is process to resolve grief
E. Despair, depression
F. Detachment from loss
G. Renewed interest, investment in others / interests
H. Mourning is process to resolve grief
1. Shock, disbelief are short term
2. Resentment, anger
3. Possible auditory, visual hallucinations
4. Possible guilt
5. Possible fear of becoming mentally ill

ASSESSMENT
A. Weight loss
B. Sleep disturbances
C. Thoughts centered on loss
D. Dependency, withdrawal, anger, guilt
E. Suicide potential

NURSING DIAGNOSIS
• A. Ineffective coping
• B. Hopelessness
• C. Sleep pattern disturbances
• D. Disturbed thought process
• E. Risk for violence, self-directed

PLANNING
Goals: Client/Family will
• 1. Discuss responses to loss
• 2. Resume normal sleeping/eating patterns
• 3. Resume ADL as they accept loss

IMPLEMENTATION
• A. Encourage client/family to express feelings
• B. Accept negative feelings/ defenses
• C. Employ emphatic listening
• D. Explain mourning process and relate to client/ family responses
• E. Refer client/ family to support groups

EVALUATION
Client/ Family has:
1. Expressed feelings
2. Progressed through mourning process
3. Seeked necessary support groups