Nursing care of the elderly patients

medical surgical nursing , nursing care of elderly patient with disease conditions and different care given to them,it contain introduction , definition, nursing care, patient teaching, diet management, research.

1. Nursing Care of the ELDERLY Name of the evaluator: Mrs. Mamta Toppo Associate Professor College of Nursing RIMS, Ranchi Name of the student: Priyanshu Sainy Roll no.-24 Basic B.Sc. Nursing 3 rd year College of Nursing, RIMS MEDICAL- SURGICAL NURSING- II Date : 11/08/2020

2. Contents Introduction to care of elderly Terminology Geriatric Nursing Assessment of the older adult Biological aspects of aging Psychosocial aspects of aging Sociocultural aspects of aging Sexual aspects of aging Theories of Aging Elder Abuse Uses of Aids and prosthesis Role of Nurse in Geriatric care New research done Summary Evaluation Bibliography

3. THE NORMAL AGING PROCESS

4. Introduction to care of elderly ELDERLY is an individual over 65 years old who have a functional impairments. Elderly care is the fulfilment of the special needs and requirements that are unique to senior citizens. This broad term encompasses such services as assisted living, adult day care, long term care, nursing homes, hospital care, and In-Home care. Providing nursing care for older people is a major area of responsibility in the caseloads of nurses in almost all health care settings. Nurses are accustomed to a multidisciplinary approach in giving care. In the field of geriatrics and gerontology, nurses will undoubtedly continue to assume multidisciplinary roles, particularly in home care and long term care settings. When caring for older patients, we need to take into account the physiologic and biologic changes that normally occur during aging and to understand older adults’ special health requirements. Also, the effects of drugs on older patients should be understood.

5. TERMINOLOGY Geriatrics - Geriatrics come from the Greek word GERAS - Old age and IATRIKQS - Branch of Medical. Hence, it is defined as “the branch of medicine concerned with medical problems and care of old people.” Gerontology : Gerontology is the study of all aspects of the aging process and its consequences in humans. Gerontology achieves a level of wellness consistent with the changes of aging. Aging : It is defined as a maturational process that creates the need for individual adaptation because of physical and psychological declines that occur during a lifetime.

6. Geriatric Nursing Geriatric Nursing is the specialty that concerns itself with the provision of nursing services to geriatric or aged individuals. This is an outline of the state of art for geriatric care that are useful to a nurse practitioner who encounters aging person in practice. Due to their complexity, aged people always deserve personal attention. Nurses address physical, psycho-social, cultural and family concerns as well as promoting health and emphasizing successful aging.

7. Assessment of the older adult Careful assessment is the foundation of care for all patients, regardless of age. To identify the problems and needs of older adults, nurse must integrate a sound theoretical knowledge of the geriatric population with best assessment skills. Components of geriatric assessment Functional Assessment – it is the measurement of patient’s ability to complete functional tasks and are used to evaluate the older adult’s overall well-being & self care abilities.

8. Assessment tools To rank the patient’s ability to perform 6 functions: Bathing Dressing Toileting Transfer Continence Feeding To evaluate their needs to support independent living: Use telephone Shop Do laundry Manage finances Take medications Prepare meals To assess a patient’s self care capacity such as : Feeding Moving here and there Bathing Going up and down the stairs Dressing Controlling bladder, etc. It is a multidimensional assessment tool to evaluate 5 areas: Social resources Economic resources Physical health Mental health ADL

9. Physical Examination - It is the second component of the health assessment. It focuses on several aspects: Obtaining health history Current health status Medical history Review of body systems Nutrition Assessment : It includes evaluation of medical diagnosis, measurements of anthropometric parameters and biochemical indices, and review of medications.

10. Normal aging has four aspects: Biological aspects of aging Psychological aspects of aging Sociocultural aspects of aging Sexual aspects of aging

11. BIOLOGICAL ASPECT OF AGING

12. Individuals are unique in their psychological and physical aging process. As the individual ages, there is a quantitative loss of cells and changes in many of enzymatic activities within cells. Age related changes occurs at different rate in different people. NERVOUS SYSTEM Decreased speed of neural conduction Decreased number of brain cells Decrease in cell of the nerve fibers Decreased neurotransmitters Decline in memory for recent events Decreased rapid eye movement sleep Decreased cerebral circulation

13. SENSORY CHANGES Eye: Diminished ability to focus on close objects. Decreased visual acuity The eye’s external changes give evidence of advancing age. These changes result from loss of orbital fat, loss of elastic tissue and decreased muscle tone. The cornea flattens which reduces the refractory power The retina of older individual becomes thinner because of fewer neural cells and receives only 1/3 rd of the amount of light that of a younger person. Due to this problem in reading, not able to see in dim light and also have difficulty in color perception. The lens of the eye loses its elasticity and increases in density.

14. Ear: Hearing problem Cerumen gland are reduced in number dry and hard ear wax, along with itching. Degenerative changes occur in ossicles contributing to hearing loss Presbycusis is the term used to describe hearing loss associated with normal aging. Taste and Smell: Decreased ability to taste and smell Very rarely the capacity to smell diminishes. Taste perception and taste discrimination decreases as the age advances.

15. CARDIOVASCULAR SYSTEM Decreased physical demands and activity of heart. Slower heart rate and reduce cardiac output Decreased contractility Impaired coronary artery blood flow Less oxygen and blood supply to organ so that it affects the function of organ Decreased altered preload and after load Increased atherosclerotic plaques and blood pressure Diminished ability to respond to stress

16. MUSCULOSKELETAL SYSTEM Decreased bone density Decreased muscle size and strength Decreased joint cartilage In aging, the increased parathyroid hormone, decreased vitamin D and calcitonin also play role in calcium loss in older people. In women, estrogen deficiency, calcium malabsorption, lifestyle factors can result in bone loss. Aging brings decline in numbers of muscles resulting in reduced muscle mass. The muscle strength also reduces especially due to lack of exercise.

17. Psychological aspects of aging

18. Memory Functioning Short term memory deteriorate with age, long term memory does not show similar changes. A well educated and mentally active person does not exhibit such changes in faster rate. The time required for memory scanning is longer for both recent and remote recall among older people. This can be attributed to social or health factors (stress, fatigue, illness), but it can also occur with certain physiological changes due to aging.

19. Intellectual functioning Fluid abilities or abilities involved in solving novel problems, tend to decline from adult period to old age. High degree of regularity in intellectual function present on most of the old age people. Intellectual abilities of older people do not decline, but do become obsolete. Their formal educational experience is reflected in their intelligence performance.

20. Learning ability The ability to learn is not decline by age. The slowing of reaction time with age and over arousal of CNS are noted in old age. It may lead to lower levels of performance in tasks which requires high efficiency. Ability to learn continue throughout the life, although strongly influenced by personal interests and preferences. Accuracy of performances diminishes,

21. Loss and grief By the individuals reach 60-70 yrs of age, they have experienced numerous losses and mourning has become a life long process. It is impossible for some of the older age people to complete the grief process in response to one loss before the other loss occurs. This can further predispose to depression. Dealing with death Death anxiety among the elderly is more of a myth than reality. The feeling of abandonment, pain and loss may lead to fear or anxiety in elderly.

22. SOCIOCULTURAL ASPECTS OF AGING

23. Old age brings many important socially induced changes. Some of them have potential for negative effect on both the physical and mental well-being of older persons. They want protection from hazards and weariness of every day tasks They want to be treated with respect and dignity and also want to die with respect and dignity. In developing countries and Asian countries the aged are awarded a position of honour, that place emphasize on family cohesiveness. In industrialized countries many negative stereotyped perspectives on aging still persisting, aged are always tires or sick, slow and forgetful, isolated and lonely, unproductive, etc. The status of elderly may improve with time as the number of elder person increases world wide.

24. SEXUAL ASPECTS OF AGING

25. Changes in females Menopause may begin anytime during the 40s or early 50s. Gradual decline in the functioning of the ovaries and subsequent reduction in the production of estrogen. The walls of the vagina become thin and inelastic and vaginal lubrication decreases. Orgasmic uterine contractions become spastic. All these changes result in vaginal burning, pelvic aching, irritability, etc In some women these changes result in avoidance of sexual intercourse. These symptoms are more likely to occur with infrequent intercourse of only one time a month or less Regular and more frequent sexual activity result in a greater capacity for sexual performance.

26. Changes in males Testosterone production decline gradually as the age increases As a result of these hormonal changes the erection takes place slowly and requires more genital stimulation to achieve. The volume of ejaculate decreases and the force of ejaculate lessens The testis become smaller, but most men continue to produce viable sperm well in to old age.

27. Factors affecting ageing

28. The aging process depends on a combination of both genetic and environmental factors. Recognizing that every individual has his or her own unique genetic makeup and environment, which interact with each other, that is why the aging process can occur at such different rates in different people. Environmental stress associated with exposure to excessive heat and light trigger the activity of aging genes. Genetic and Environmental Factors

29. Behaviors of a healthy lifestyle: Not smoking Drinking alcohol in moderation Exercising Getting adequate rest Eating a diet high in fruits and vegetables Coping with stress Having a positive outlook Aging process in men is mainly brought about by over consumption of alcohol and heavy smoking. Lack of exercise, inadequate rest or sleep, mental stress show symptoms of early aging. Others factors like regular consumption of excessive spicy food and caffeine renders an old look. Sloth and sluggish lifestyle makes one feel old. However, many environmental conditions, such as the quality of health care that you receive, have a substantial effect on aging. A healthy lifestyle is an especially important factor in healthy aging and longevity. Life style:

30. Aging and disease are related in subtle and complex ways. Several conditions that were once thought to be part of normal aging have now been shown to be due to disease processes that can be influenced by lifestyle. Osteoporosis and arthritis are the main factors governing aging process in women. The toxins produced in Parkinson’s disease degenerate the neurons that hinders the memory of brain. In Alzheimer’s disease, a substance known as amyloid is produced that destroys the brain cells. All these interferes with the normal aging process. Disease

31. T heories of A ging

32. Contt.

33. Elder Abuse Elder abuse is any form of mistreatment that results in harm or loss to an older person. Elder abuse tends to take place where the senior lives: most often in the home where abusers are apt to be adult children; other family members such as grandchildren; or spouses of elders. The personal losses associated with abuse can be devastating and include the loss of independence, homes, life savings, health, dignity, and security. Victims of abuse have been shown to have shorter expectancies than non-abused older people.

34. RISK FACTORS for Elder Abuse Poor health and functional impairment in older person Cognitive impairment Substances abuse or mental illness Dependence of the abuse on the victims Shared living arrangement Social isolation History violence RISK FACTORS among Caregivers Among caregivers, significant risk factors for elder abuse are: Inability to cope with stress Depression {common} Lack of support from other potential caregivers Substance abuse The caregiver’s perception that taking care of the elder is burden some and without psychological reward.

35. TYPES

36. TYPES Physical Abuse - Use of physical force against an older adult that may result in bodily injury, physical pain or impairment. Emotional abuse - Infliction of anguish, pain, or distress on an older adult through verbal or nonverbal acts. Financial abuse - Illegal or improper use of an older adult’s funds, property or assets. Sexual abuse - Non-consensual sexual contact of any kind with an older adult. Neglect - Refusal or failure to fulfil any part of a person’s duties to an older adult. Anguish-severe mental pain Infliction- cause Non- consensual= not agreed to by one

37. Use of Aids and Prosthesis Prosthesis: It is an artificial device used to replace a missing body part, such as a limb, tooth, eye or heart valve. It refers to the replacement of a missing body part with such a device. In medicine, prosthesis is an artificial extension that replaces a missing body part. Dental prosthesis is an artificial appliance which is used as a substitution for the replacement of teeth. A CAST PARTIAL DENTURE

38. Hearing aids : It is an electroacoustic body worn apparatus which typically fits in or behind the wearer’s ear, and is designed to amplify and modulate sound for the wearer. They are incapable of truly correcting a hearing loss; they are an aid to make sounds more accessible. Behind the ear In the ear aid Pocket model

39. Role of Nurse in Geriatric care Acute Care Gather medical, family and psychological history Perform patient assessment Explain diagnosis and treatment to the patient and family Work closely with patient, family and other health care professionals Maintain hydration, nutrition, aeration and comfort Provide medications and treatment and evaluate response Administer emergency treatment when necessary Initiate discharge planning & coordinate referral to community agencies Serve as patient advocate Inform doctor of any change in patient’s condition

40. Long term Care Gather medical, family and psychological history Perform patient assessment Involve patient and family in preparation & implementation of nursing plan Promote the atmosphere that emphasizes quality living, not disease and dying Ensure that patient receives medical, dental, eye care Maintain hydration, nutrition, aeration and comfort Provide medications, treatment, rehabilitative exercises and evaluate response Teach and advise patient and family Perform emergency measure when necessary Serve as patient advocate Inform doctor of any change in patient’s condition

41. Community Care Identify health, social or economic needs. Refer elderly person to professional or agency best able to meet needs. Explain diagnosis and treatment to the patient and family Evaluate compliance with and response to treatment. Use clinic and home visits for health promotion. Teach and advise patient and family Evaluate elderly person’s ability to live independently Become advocate for elderly persons Encourage elderly to become advocate on his own self.

42. Older patients’ perception of engagement in functional self-care during hospitalization: A qualitative study: Highlights • Vital to raise awareness on importance of functional self-care and empower older patients to break from passive role. • Important to promote care philosophies and design age-friendly care facilities that facilitate functional self-care. • Functional self-care engagement can be included in mutual goal setting with patients. • Fall prevention needs to balance between decreasing movements and letting patients ambulate to participate in self-care. a. Department of Nursing, Tan Tock Seng Hospital, 11 Tan Tock Seng, Singapore b. Alice Lee Centre of Nursing Studies, National University of Singapore, Singapore Received 18 July 2019, Revised 8 November 2019, Accepted 11 November 2019, Available online 29 November 2019 NEW RESEARCH

43. Abstract Background Participation in functional self-care can delay functional decline during older adults’ hospitalization. Aims To explore facilitators and barriers to older adults’ participation in self-care during hospitalization, in an Asian setting. Methods Qualitative descriptive study using in-depth interviews, in a Singaporean hospital. Older adults were recruited using purposive sampling. Interviews were recorded and transcribed verbatim. Thematic analysis was used. Results Data saturation was reached with 17 participants. Three themes were identified: patient factors, healthcare provision and hospital environment. Facilitators included: patients' positive mindset, nurses’ encouragement, and age-friendly environment. Barriers included: patients’ and nurses’ attitudes towards functional self-care, patients’ and nurses’ fear of inpatient falls, healthcare-imposed restrictions. Patients’ notion of a ‘good patient’ can either facilitate or hinder their self-care engagement. Conclusion This study offers insights from older adults in an Asian hospital setting. The findings can be used to develop strategies, care models, and facilities to promote functional self-care during hospitalization.

44. Improving care for older adults in the Emergency Department warrants greater investment in geriatric nursing—Stat! a . Department of Physiological Nursing, University of California, 2 Koret Way, Box 605N, San Francisco, CA 94143, United States b . Global Brain Health Institute, University of California, San Francisco, United States Available online 13 April 2020. Keywords: Emergency Department Geriatrics Nursing Care delivery Innovations The recent COVID-19 pandemic, with its high infection and death rates among older adults, has underscored just how critical the role of the Emergency Department (ED) is in the care of older adults. But even in “normal” times, older adults–particularly the oldest old and those with underlying health conditions–frequently rely on the ED for care. In the United States (U.S.), older adults account for over 15% of the almost 150 million visits to the ED annually. Older adults in the ED tend to have a higher level of medical urgency, are more likely to undergo extensive diagnostic testing, have longer stays in the ED, and are more likely to be admitted to the hospital subsequent to the ED visit. These statistics are even more stark for older adults with additional vulnerabilities, such as older adults with dementia. Research 2

45. Despite their high utilization of the ED, the traditional ED environment is poorly suited to address the complex needs of older adults. Both the physical design and the processes of care in the ED are designed for the purpose of rapid triage and diagnosis—goals which are not necessarily aligned with the characteristics and needs of older adults. For example, equipment crowded into a small exam area and slippery linoleum floors increase fall risk for older adults. Constant beeping of equipment, lack of space for caregivers to accompany patients, and bright fluorescent lights on all night may increase risk of delirium. Providers are expected to assess patients in mere minutes, but it is difficult if not impossible to assess the complex medical conditions and subtle presentations of older adults under such circumstances. As a result of the mismatch between care delivery in the ED and needs of older adults, older adults often experience poor outcomes as a result of ED visits. These poor outcomes are well-documented, and include falls, delirium, functional decline, and increased mortality. Trailblazing initiatives over the past couple of decades have highlighted the importance of improving care for older adults in the ED, and we see new care models emerging. In 2014, multiple professional organizations–including the American College of Emergency Physicians and the Emergency Nurses Association among others–came together to create the Multidisciplinary Geriatric Emergency Department Guidelines. The purpose of these guidelines was to create standardized recommendations to guide the optimization of care of older adults in the ED. The guidelines include recommendations on structure and processes of care, including staffing, care transitions, infrastructure and policies and procedures, among many others. In 2018, the American College of Emergency Physicians began accrediting facilities as geriatric Emergency Departments.

46. Due to these and other efforts, geriatric Emergency Department interventions and innovations (GEDI's) are becoming more common. 6  The gold standard of these innovations is the standalone geriatric ED unit. These units are modeled upon similar approaches to pediatric and psychiatric ED's and have designated areas designed specifically for the special needs of older adults. Physical spaces incorporate the needs of older adults, including nonskid floors, handrails, lighting that follows diurnal patterns, and pressure-reducing air mattresses. All staff are educated in geriatric principles and specialized geriatrics providers are available for consult. Processes are implemented for screening older adults for dementia, delirium, and other geriatric syndromes. Nursing has been at the forefront of these efforts to improve care for older adults in the ED across the spectrum of education, practice, and research. The Nurses Improving Care for Healthcare Elders (NICHE) has designed resources for patients and caregivers to help them navigate the ED, 7  while the Emergency Nurses Association has developed a comprehensive course on Geriatric Emergency Nursing Education aimed at training nurses to improve outcomes for older adults in the ED. Another resource is the newly formed Geriatric Emergency Department Collaborative, which focuses on interdisciplinary care of the older adult in the ED. A number of research studies have examined nurse-led multidisciplinary GEDI's. For example, a study of a Transitional Care Nurse model, in which an ED nurse was trained to facilitate care transitions for older adults, reduced subsequent inpatient admissions by 5%–16%. 9  However, other studies have shown mixed results on the impacts of nurse-led interventions, demonstrating there is still more work to do to understand the best models of care. As frontline providers, nurses offer a unique perspective on caring for older adults in the ED. Nurses are the most numerous health professionals in the ED and often the first and most frequent point of contact for patients. Given their vantage point, nurses bring critical ideas for improving care for older adults in the ED, as well as help us understand when interventions fail. Bedside nurses have emphasized the need for interdisciplinary, evidence-based protocols to help prevent, detect, and manage geriatric syndromes. Put simply, there is no way to improve care for older adults in the ED without the engagement of nursing. How else can nurses take an active role in improving care for older adults in the ED? While there may not be resources to develop a standalone Geriatric ED in their institutions, nurses can advocate for smaller scale interventions that can still have a big impact. For example, institutions could implement a geriatric practitioner model, where a clinician geriatric expert, such as a geriatric nurse and/or advanced practice nurse, are available for consultations for individual patients, as well as responsible for leading education efforts on the unit. Moreover, nurse educators should ensure that they are teaching principles of geriatric care to all of their staff and students. Nurses can also help push for more financial investment in research, education, and training specific to geriatric nursing through policy advocacy. While the National Cancer Institute receives $600 billion in appropriations each year, the National Institute of Nursing Research receives a mere $300 million. Funding for the NINR should be increased and efforts should focus on testing and implementing nurse-led multidisciplinary GEDI's. Moreover, fewer than 1% of registered nurses specialize in geriatrics, and this number is declining. We need more funding to increase the number of registered and advanced practice nurses pursuing a focus on geriatrics, but it is also critical that geriatric curriculum is infused into the training of all nurses. An older adult with an active COVID-19 infection should not also have to worry about falls and delirium when presenting to the ED. It is past time to increase efforts to improve care for older adults in the ED. As the junction between the outpatient and inpatient settings, there is tremendous opportunity to improve care older adults receive not only in the ED itself, but across the spectrum of care. With increased recognition of the importance of improving care for older adults in the ED and the emergence of GEDI's, we have made some strides. But there is still a long way to go. Nursing, in particular geriatric nursing, has been and needs to continue to be at the forefront of these efforts, and funding efforts should reflect the importance of geriatric nursing to the care of older adults in the ED. Funding Dr. Hunt is supported through the National Institutes of Health ; UCSF Pepper Center; a National Palliative Care Research Center Career Development Award; and the Global Brain Health Institute/Atlantic Philanthropies.

47. Summary Elderly care is the fulfilment of the special needs and requirements that are unique to senior citizens. This broad term encompasses such services as assisted living, adult day care, long term care, nursing homes, hospital care, and In-Home care. Components of geriatric assessment are : Functional assessment Physical Examination Nutrition Assessment Normal aging has four aspects: Biological aspects of aging Psychological aspects of aging Sociocultural aspects of aging Sexual aspects of aging Role of nurse includes acute care, long term care and community care.

48. Evaluation What is elderly care? What is geriatric nursing? What are the assessment tools of functional assessment? What are the changes that occur in nervous system? Point out the psychosocial theories of aging. Name the different types of hearing aids.

49. Bibliography Ansari Javed , A Textbook of Medical Surgical Nursing-II, PV publications, Page no-1067-1108 Suddarth’s and Brunner, Textbook of Medical Surgical Nursing, Vol-II, South Asian Edition, Wolters Kluwer www.wikipedia.com www.journals.elsevier.com www.slideshare.com