CARE OF THE CHRONICALLY ILL AND THE OLDER PERSON It deals with concepts, principles and techniques of nursing

g care management of those with chronic illness and older persons PRINCIPLES OF GERONTOLOGY Health promotion, health protection, disease prevention and treatment of disease with emphasis on evidence-based best practices and current clinical practice guidelines. Aging is an inevitable and steadily progressive process begins at the moment of conception and continues throughout the remainder of life. The final stage of life consisting of old age, can be the best or worst time of life requires work and planning throughout all of the previous stages to be a successful and enjoyable period. DEMOGRAPHICS AND AGING Countries all over the world are facing demographic aging. All nations are soon will be faced with important issues regarding the provision of healthcare to older persons. In 1997 -10% (561 million) of the worlds population was age 60 and older projected to increase to 15% by 2025. LONGEVITY AND THE SEX DIFFERENTIAL The gender differences in life expectancy may be explained by the complex interactions between biological, social, and behavioral factors. Greater male exposure to risk factors (tobacco, alcohol, and occupational hazards) might negatively affect male life expectancy. LIFE AFTER 65 Women 65 + 19 years Men 65 can expect to live another 16. life expectancy - attributed to improved healthcare - increased use of preventive services - healthier lifestyles SENESCENCE refers to the progressive deterioration of body systems that can increase the risk of mortality as an individual gets older. GERIATRICS Often used as generic term related to the aged, but specificically refers to medical care of the aged SOCIAL GERONTOLOGY

Concerned with the social aspects of aging versus biological or psychological Geropsychology branch of psychology concerned with helping older persons and their families maintain wellbeing, overcome problems & achieve maximum potential during later life Geropharmacology is the study of pharmacology as it relates to older adults GERONTOLOGICAL NURSING It involves advocating for the health of older persona at al levels of prevention ROLES OF THE GERONTOLOICAL NURSE Provider of care Teacher Manager Advocate Research consumer THEORIES OF AGING Theories of aging fall into several groups, including biological, psychological, and sociological theories. BIOLOGICAL AGING THEORIES PROGRAMMED THEORIES hypothesize that the bodys genetic codes contain instructions for the regulation of cellular reproduction and death. Programmed Longevity aging is the result of the sequential switching on and off of certain genes- with aging, associated functional deficits are manifested. PROGRAMMED THEORIES Endocrine Theory Biological clocks act through hormones to control the pace of aging. Proponents of this theory ascribe to the use of various natural and synthetic hormones, such as human growth hormone, to slow the aging process Immunological Theory A programmed decline in immune system functions leads to an increased vulnerability to infectious disease, aging and eventual death. ERROR THEORIES environmental assaults and the bodys constant need to manufacture energy and to fuel metabolic activities cause toxic by-products may eventually impair normal body function and cellular repair. Wear and Tear Theory Cells and organs have vital parts that wear out after years of use. master clock controls all organs

cellular function slows down with time less efficient at repairing body malfunctions that are caused by environmental assaults. Cross Link Theory an accumulation of cross-linked proteins resulting from the binding of glucose (simple sugars) to protein causes various problems. Once the binding occurs, the CHON cannot perform normally and may result in visual problems like cataracts or wrinkling and skin aging. Free Radical Theory accumulated damage caused by oxygen radicals causes cells and eventually organs, to lose function and organ reserve. The use of antioxidants and vitamins is believed to slow this damage. Somatic DNA Damage Theory Genetic mutations occur and accumulate with increasing age - cells deteriorate and malfunction. PSYCHOLOGICAL AGING THEORIES JUNGS THEORY OF INDIVIDUALISM the shift of focus is away from the external world (extroversion) toward the inner experience (introversion). search for answers to many of lifes riddles and try to find the essence of the true self. To age successfully, the older person will accept past accomplishments and failures. ERICKSONS DEVELOPMENTAL THEORY According to Erickson, there are 8 stages of life with developmental tasks to be accomplished at each stage. ego integrity versus despair the older adult will become preoccupied with acceptance of eventual death without becoming morbid or obsessed with these thoughts. Older persons who have not achieved ego integrity may look back in their lives with dissatisfaction and feel unhappy, depressed, or angry over what they have done or failed to do. SOCIOLOGICAL AGING THEORIES DISENGAGEMENT THEORY Introduced by Cummings and Henry

the appropriate pattern of behavior in later life is for the older person to engage in a mutual and reciprocal withdrawal. Thus, when death occurs, neither the older individual nor the society is disadvantaged and social equilibrium is maintained ACTIVITY THEORY contradicts the disengagement theory; older adults should stay active and engaged if they are to age successfully. When retirement occurs, replacement activities must be found. CONTINUITY THEORY successful aging involves maintaining or continuing previous values, habits, preferences, family ties, and all other linkages that have formed the basic underlying structure of adult life. Older age is not viewed as a time that should trigger major life readjustment, but rather just a time to continue being the same person. AGE STRATIFICATION THEORY Physical impairment is associated with fewer social contacts, less social support, depression and lower life satisfaction Changing status of older adults due to differences in cohort groups PERSON-ENVIRONMENT-FIT THEORY Functional competence is affected by multiple intrapersonal conditions such as ego, strength, motor skills, biologic health, cognitive capacity, sensoriperceptual capacity as well as external conditions posed by the environment NURSING THEORIES OF AGING Functional consequences theory o Environment & biopsychosocial consequences impact functioning o Nursing role is risk reduction to minimize age-associated disability in order to enhance safety & quality of living Theory of thriving o Failure to thrive results from discord between the individual and his or her environment or relationships o Nurses identify and modify factors that contribute to disharmony among these elemnts. THE AGING POPULATION

 About 1/8 Americans is aged 65 and older in 2005. In the Philippines 14.1% is aged 65 and older Changes in life expectancy were mainly due to improved sanitation and advances in medical care Older population today are challenged in dealing with chronic diseases EFFECTS OF ETHNICITY Aging population comprises 22% of the minority Losses (spouse, friends, independence, levels of function, status in society) coupled with socio economic status & racial discrimination put these group at increased risk for poor health outcomes. MORTALITY & MORBIDITY In 2001 the leading cause of death was o Diseases of the heart o Malignant neoplasms o CVA o Chronic Lower Respiratory diseases o Influenza o Pneumonia o Diabetes AGING CHANGES THAT AFFECT COMUNICATION The ability to communicate depends on o Physiological Process Listening, Speaking, Gestures, Reading, Writing, Touching, Moving. o Psychological Process Cognitive process (attention, memory, selfawareness, oranization & reasoning) SENSORY MODALITIES INVOLVED IN COMMUNICATION Vision o 70% of all sensory information comes from the eyes o Gestures and non verbal behavior (blink, tears smile) Hearing o Reception of communication o Physical properties (Pitch & Timber) Other

o o

o SPEECH Primary form of communication Requires both visual & auditory Involves pronunciation & articulation for form a language DISABILITY Results in modifying their style in communication to others ROLE OF THE BRAIN IN COMMUNICATION ORGANIZE INFORMATION RESPOND TO CHANGE RECOGNIZES COMPLETE OR AMBIGUOUS INFORMATION AGE RELATED CHANGES IN THE EYE LENS o Changes in color with age (amber or opaque) o Becomes flattened and less flexible o Inability to focus and see certain colors AGE RELATED CHANGES IN THE EYE IRIS & PUPILS o At 50 pupillary reflex respond move slowly o Senile miosis (size of the pupil declines) o Difficult to see illumination AREAS OF THE BRAIN IMPORTANT FOR COMMUNICATION Cortex o Large sheet of neurons that covers the brain o Contains sensory ,motor information & thoughts Thalamus o Relays sensation to the brain Forebrain o Interprets & integrates sensory information based on past experiences NORMAL & PATHOLOGICAL CHANGES & THEIR IMPACT IN COMMUNICATION

Touch may be used as substitute for sight Chemical senses of smell (ofaction) Movement/Gestures

MODALITY Normal Changes MODALITY Normal Changes

Pathologica Impact on l Changes Pathological Communication Impact on Changes Communication

MODALI TY COGNITI VE

Normal Changes

Pathological Changes Delirium

Impact on Communication

Decline in information processing speed, divided attention, sustained attention ability to perform visuospatial MODALITY Normal task and short Changes term memory MOVEMENT

Depending on cognitive Dementia impairment, Disorientation & Alzheimers inappropriate Disease response, difficulties in finding words, depression, loss of Pathologica Impact on insight, isolation, l Changes Communication inability to earn new information Reduced ability to communicate nonverbal information, insecurity & loss of independence

VISION PSYCHOLOG In general, Macular Changes in lens Depression Slowed response Isolation, pupil & iris. Insecurity, ICAL older adultsdegeneration lack of motivation Results in poor Diabetic Depression, reports levels decrease in social visual acuity, retinopathy Embarrassment of activity presbyopia Glaucoma Decrease in satisfaction Senile cataracts exchange of increase that are sensitivity to Retinal communication similar to light and glare detachments younger adults

What is Chronic Illness An illness that persists for a long period of time (3 months or more) The term "chronic" comes from the Greek
MODALITY Normal Changes Pathological Impact on Changes Communicatio n

Due to decline Parkinsons in many disease sensory Disability organs, cognitive functioning & bodily strength results in reduced velocity and accuracy & greater variability across individuals Pathological Changes

HEARING

Conductive Hearing loss Inatention, problems due to repetitive Sensori exposure to questions, neural noise, isolation, problems ototoxic insecurity, (Presbycusis) substances, decrease in results in loss medications, social in sensitivity poisons, functioning, to pitch with acute trauma depression , high & certain loneliness, frequency medical difficulties in consonants, conditions following poor word instructions recognition

chronos. In ancient Greece, the "father of

MODALI TY SPEECH & LANGUA GE Normal Changes Pathological Changes Impact on Communication Difficulties in producing Language, coherent meaningful & verbal communication Difficulty in understanding verbal communication

MODALI TY TOUCH

Normal Changes

Impact on Communication Use of mouth to explore the quality of the objects safety might be compromised

Reduction in Dementia, the no of Parkinsons or receptors Diabetes can impact Reduction of somatosensory bloodflow functioning Results in a reduction in tactile & vibration sensations, decreased sensitivity to warm & cold stimuli

Decrease Dysarthia (CVA) respiration Overproduction Verbal apraxia (paraysis of speech of mucus/reduced muscles) saliva Loss of teeth Decrease Aphasia elasticity of COPD muscle tone Mechanical Results in ventilation shaky & breathy voice, Laryngectomy tremulous & frequent attempts of throat clearing

medicine" Hippocrates distinguished diseases that were acute (abrupt, sharp and brief) from those that were chronic. In medicine, a chronic disease is a disease that is long-lasting or recurrent. The term chronic describes the course of the disease, or its rate of onset and

development. A chronic course is distinguished from a recurrent course; recurrent diseases relapse repeatedly, with periods of remission in between. As an adjective, chronic can refer to a persistent and lasting medical condition. Chronicity is usually applied to a condition that lasts more than three months. Diabetes is a good example. The definition of a disease or causative condition may depend on the disease being chronic, and the term chronic will often, but not always appear in the description: Arthritis Chronic fatigue syndrome Chronic obstructive pulmonary disease Chronic renal failure Hepatitis Leukemia lupus erythematosus POTS REVIEW OF PATHOPHYSIOLOGY Hypertension Hypertension (HTN) or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. It is the opposite of hypotension. Persistent hypertension is one of the risk factors for stroke, myocardial infarction, heart failure and arterial aneurysm, and is a leading cause of chronic kidney failure Classification Primary High blood pressure with no obvious medical cause 90-95% Secondary 5-10% Caused by other conditions that affect the kidneys, arteries, heart or endocrine system. Blood pressure is usually classified based on the systolic and diastolic blood pressures. Systolic blood pressure is the blood pressure in vessels during a heartbeat. Diastolic blood pressure is the pressure between heartbeats. A systolic or the diastolic blood pressure measurement higher than the accepted normal values for the age of the individual is classified as prehypertension or hypertension Signs & Symptoms Mild to moderate essential hypertension is usually asymptomatic

Accelerated hypertension is associated with headache, drowsiness, confusion, vision disorders, nausea, and vomiting. These symptoms are collectively called hypertensive encephalopathy. [12] Hypertensive encephalopathy is caused by severe small blood vessel congestion and brain swelling, which is reversible if blood pressure is lowered Secondary hypertension Hypertension combined with obesity distributed on the trunk of the body, accumulated fat on the back of the neck ('buffalo hump'), wide purple marks on the abdomen (abdominal striae), or the recent onset of diabetes suggests that an individual has a hormone disorder known as Cushing's syndrome. Hypertension caused by other hormone disorders such as hyperthyroidism, hypothyroidism, or growth hormone excess will be accompanied by additional symptoms In pregnancy Hypertension in pregnant women is one symptom of pre-eclampsia. Preeclampsia can progress to a lifethreatening condition called eclampsia, which is the development of protein in the urine, generalized swelling, and severe seizures. Other symptoms indicating that brain function is becoming impaired may precede these seizures such as nausea, vomiting, headaches, and vision loss. In children Some signs and symptoms are especially important in newborns and infants such as failure to thrive, seizures, irritability, lack of energy, and difficulty breathing.[20] In children, hypertension can cause headache, fatigue, blurred vision, nosebleeds, and facial paralysis Causes: Essential hypertension the most prevalent hypertension type 9095% of hypertensive patients factors such as sedentary lifestyle,smoking, stress, visceral obesity, potassium deficiency (hypokalemia),obesity(more than 85% of cases occur in those with a body mass index greater than

25),salt (sodium) sensitivity,alcohol intake,and vitamin D deficiency Secondary hypertension Hypertension results in the compromise or imbalance of the pathophysiological mechanisms, such as the hormone-regulating endocrine system, that regulate blood plasma volume and heart function. Many conditions cause hypertension. Some are common, well-recognized secondary causes such as Cushing's syndrome,[36] which is a condition where the adrenal glands overproduce the hormone cortisol Nursing Management NURSING DIAGNOSIS FOR SEVERE HYPERTENSION: 1. Risk for decreased cardiac output 2. Activity intolerance 3. Acute headache pain 4. Imbalanced nutrition more than body requirements 5. Ineffective coping 6. Deficient knowledge (Learning Need) regarding condition, treatment plan, selfcare, and discharge needs Heart Disease Heart disease or cardiopathy is an umbrella term for a variety of diseases affecting the heart has been divided into four sections that focus on heart dysfunction and its associated characteristics o Hypertrophy, cardiomyopathy and failure o Vascular dysfunction and disease; o Ischemic heart disease; o and Novel therapeutic interventions. are the class of diseases that involve the heart or blood vessels (arteries and veins).While the term technically refers to any disease that affects the cardiovascular system it is usually used to refer to those related to atherosclerosis (arterial disease) Types : Coronary Heart Disease refers to the failure of the coronary circulation to supply adequate circulation to cardiac muscle and surrounding tissue. Coronary heart disease is most commonly equated with Coronary artery disease although coronary heart disease can be due to other causes, such as coronary vasospasm.

refers to the failure of the coronary circulation to supply adequate circulation to cardiac muscle and surrounding tissue. Coronary heart disease is most commonly equated with Coronary artery disease although coronary heart disease can be due to other causes, such as coronary vasospasm. Coronary artery disease is a disease of the artery caused by the accumulation of atheromatous plaques within the walls of the disease. arteries that supply the myocardium. Angina pectoris (chest pain) and myocardial infarction (heart attack) are symptoms of and conditions caused by coronary heart Coronary Artery Disease (CAD or atherosclerotic heart disease) is the end result of the accumulation of atheromatous plaques within the walls of the coronary arteries[1] that supply the myocardium (the muscle of the heart) with oxygen and nutrients. After decades of progression, some of these atheromatous plaques may rupture and (along with the activation of the blood clotting system) start limiting blood flow to the heart muscle. The disease is the most common cause of sudden death, [3] and is also the most common reason for death of men and women over 20 years of age Statistics half of healthy 40-year-old males will develop CAD in the future, and one in three healthy 40-year-old women. Pathophysiology Limitation of blood flow to the heart causes ischemia (cell starvation secondary to a lack of oxygen) of the myocardial cells. Myocardial cells may die from lack of oxygen and this is called a myocardial infarction (commonly called a heart attack). It leads to heart muscle damage, heart muscle death and later myocardial scarring without heart muscle regrowth. Chronic high-grade stenosis of the coronary arteries can induce transient ischemia which leads to the induction of a ventricular arrhythmia, which may terminate into ventricular fibrillation leading to death. CAD is associated with smoking, diabetes, and hypertension. A family history of early CAD is one of the less important predictors of CAD. Most of the familial association of coronary artery disease are

related to common dietary habits. Screening for CAD includes evaluating high-density and low-density lipoprotein (cholesterol) levels and triglyceride levels. Despite much press, most of the alternative risk factors including homocysteine, C-reactive protein (CRP), Lipoprotein (a), coronary calcium and more sophisticated lipid analysis have added little if any additional value to the conventional risk factors of smoking, diabetes and hypertension. Angina Angina (chest pain) that occurs regularly with activity, after heavy meals, or at other predictable times is termed stable angina and is associated with high grade narrowings of the heart arteries. The symptoms of angina are often treated with betablocker therapy (metoprolol or atenolol). Nitrate preparations such as nitroglycerin, which come in short-acting and longacting forms are also effective in relieving symptoms but are not known to reduce the chances of future heart attacks. Many other more effective treatments, especially of the underlying atheromatous disease, have been developed. Angina that changes in intensity, character or frequency is termed unstable. Unstable angina may precede myocardial infarction, and requires urgent medical attention. It may be treated with oxygen, intravenous nitroglycerin, and aspirin. Interventional procedures such as angioplasty may be done Characteristics of CAD Typically, coronary artery disease occurs when part of the smooth, elastic lining inside a coronary artery (the arteries that supply blood to the heart muscle) develops atherosclerosis. With atherosclerosis, the artery's lining becomes hardened, stiffened, and swollen with all sorts of "grunge" - including calcium deposits, fatty deposits, and abnormal inflammatory cells - to form a plaque. Deposits of calcium phosphates in the muscular layer of the blood vessels appear to play not only a significant role in stiffening arteries but also for the induction of an early phase of coronary arteriosclerosis. This can be seen in a so-called metatstatic mechanism of calcification as

it occurs in chronic kidney disease and hemodialysis . Although these patients suffer from a kidney dysfunction, almost fifty percent of them die due to coronary artery disease. Plaques can be thought of as large "pimples" that protrude into the channel of an artery, causing a partial obstruction to blood flow. Patients with coronary artery disease might have just one or two plaques, or might have dozens distributed throughout their coronary arteries Symptoms & Predisposing Factors Chest pain or Angina pectoris with physical stress; the pain may spread to the left arm or the neck, back, throat, or jaw. There might be present a numbness (paresthesia) or a loss of feeling in the arms, shoulders, or wrists Coronary angiography demonstrates normal coronary arteries, i.e. no blockages or stenoses can be detected in the larger epicardial vessels Consistent response to sublingual nitrates. Postmenopausal or menopausal status No inducible coronary artery spasm present during cardiac catheterization Characteristic ischemic ECG changes during exercise testing Characteristic ischemic ECG changes during exercise testing ST segment depression and angina in the presence of left ventricular wall perfusion abnormalities during thallium or other stress perfusion test Diagnostic Tests Baseline electrocardiography (ECG) Exercise ECG Stress test Exercise radioisotope test (nuclear stress test, myocardial scintigraphy) Echocardiography (including stress echocardiography) Coronary angiography Intravascular ultrasound Magnetic resonance imaging (MRI) Risk Factors Risk factors can be classified as o Fixed: age, sex, family history o Modifiable: smoking, hypertension, diabetes mellitus, obesity, etc. Hemostatic Factors:High levels of fibrinogen and coagulation factor VII are associated with an increased risk of CAD. Factor VII levels are higher in individuals with a high intake of dietary fat.

Decreased fibrinolytic activity has been reported in patients with coronary atherosclerosis. Hereditary differences/genetic polymorphisms in such diverse aspects as lipoprotein structure and that of their associated receptors, enzymes of lipoprotein metabolism such as cholesteryl ester transfer protein (CETP) and hepatic lipase (HL) , homocysteine processing/metabolism, High levels of Lipoprotein(a),a compound formed when LDL cholesterol combines with a substance known as Apoliprotein (a). Hypercholesterolemia (specifically, serum LDL concentrations) Smoking Hypertension (high systolic pressure seems to be most significant in this regard) Hyperglycemia (due to diabetes mellitus or otherwise) Type A Behavioural Patterns, TABP. Added in 1981 as an independent risk factor after a majority of research into the field discovered that TABP's were twice as likely to exhibit CAD as any other personality type. Lack of exercise Consumption of alcohol Stress Diet rich in saturated fats Diet low in antioxidants Obesity Men over 60; Women over 65 Prevention Decreasing cholesterol levels Addressing obesity and hypertension Avoiding a sedentary lifestyle Stopping smoking Exercise Preventive Diets Secondary prevention Anti-platelet therapy Omega 3 fatty acid Aspirin Principles of treatment 1. Medical treatment - drugs (e.g. cholesterol lowering medications, betablockers, nitroglycerin, calcium antagonists, etc.) 2. Coronary interventions as angioplasty and coronary stent-implantation; 3. Coronary artery bypass grafting (CABG - coronary artery bypass surgery).

Nursing Management NURSING DIAGNOSIS FOR CHRONIC HEART FAILURE (CHF) 1. Decreased Cardiac output 2. Activity intolerance 3. Excess fluid volume 4. Risk for impaired gas exchange 5. Risk for impaired skin integrity 6. Deficient knowledge (Learning Need) regarding condition, treatment plan, selfcare, and discharge needs NURSING DIAGNOSIS FOR ANGINA (CORONARY ARTERY DISEASE) 1. Acute pain 2. Risk for decreased cardiac output 3. Anxiety 4. Deficient knowledge (Learning Need) regarding condition, treatment plan, selfcare, and discharge needs NURSING DIAGNOSIS FOR MYOCARDIAL INFARCTION 1. Acute pain 2. Activity intolerance 3. Anxiety/ Fear 4. Risk for decreased cardiac output 5. Ineffective tissue perfusion 6. Risk for excess fluid volume 7. Deficient knowledge (Learning Need) regarding condition, treatment plan, selfcare, and discharge needs NURSING DIAGNOSIS FOR DYSRHYTHMIAS (INCLUDING DIGITALIS TOXICITY) 1. Risk for decreased cardiac output 2. Risk for poisoning, digitalis toxicity 3. Deficient knowledge (Learning Need) regarding condition, treatment plan, selfcare, and discharge needs NURSING DIAGNOSIS FOR CARDIAC SURGERY: POSTOPERATIVE CARE CORONARY ARTERY BYPASS GRAFT (CABG), MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS (MIDCAB), CARDIOMYOPLASTY, VALVE REPLACEMENT 1. Risk for decreased cardiac output 2. Acute pain 3. Ineffective role performance 4. Risk for ineffective breathing pattern 5. Impaired skin integrity 6. Deficient knowledge (Learning Need) regarding condition, treatment plan, selfcare, and discharge needs