Download 13 - Gerontological Family Nursing

5/25/2017
ANCY KURIAN , I MSc.(N)
1
Gerontological Family Nursing
By Dr. Nataliya Haliyash,
MD, PhD, MSN
Institute of Nursing, TSMU
Ageing
• In almost every country, the
proportion of people aged over 60
years is growing faster than any
other age group, as a result of both
longer life expectancy and declining
fertility rates.
Classification of Older Adults
• Older adults are 65-years-old and older
–
–
–
–
65-74
75-84
85-99
100 +
young old
middle old
old-old (fastest growing subgroup)
elite old
Health Care of the Older Adult
(continued)
• 50% of hospitalized clients on med-surg
units are older than 65
• 8% of elderly have 1 or more chronic
illnesses
• 50% have 2 or more chronic illnesses
• 5% live in institutional settings
Assessment Guidelines for Older
Adults
• Adjust to physiologic changes
– Be familiar with sensory changes, changes in each
body system
• Adapt assessment techniques to diminishing
energy and ability
– Allow for frequent breaks if a lengthy assessment is
needed
Assessment Guidelines
(continued)
• In addition to physical assessment, the older
adult may need assessment of:
– Ability to perform ADL’s (Activities of Daily Living
- functional assessment)
– Network of support (family and friends)
– Health beliefs in nutrition, exercise, etc.
– Sleep patterns
– Living arrangements
– Financial assessment
– Self-esteem
– View of life and acceptance of death
Reminiscence/Life Review
• An adaptive function that allows them to
recall the past and assign meaning to these
experiences
• Can be a nursing intervention to
encourage self-esteem, increase
communication skills, and increase social
interaction
Pain and the Older Adult
• May not report pain as feels it is a part of
aging
• 85% of patients in nursing homes have
pain
• Pain response: have similar pain tolerance
as young adults
Pain Assessment
• Use methods as with adults (pain scale)
• Don’t assume that if patient is busy or sleeping,
they don’t have pain; need to ask them
• If cognitive impairment is present, watch for
non-verbal cues
–
–
–
–
–
Agitation
Aggression
Wandering
Change in vital signs
Grimacing
Pain Management
• Ask what they usually use for pain and is
it working
• If acute pain, can use narcotics but may
need a decreased dose
Medications and the Older
Adult
• 25% of all prescriptions are written for
people older than 65
• Physiologic changes caused by aging
affect the activity and response of drugs
– Absorption, distribution, metabolism,
excretion
Polypharmacy
• Many older adults are using multiple
medications, use multiple pharmacies,
have multiple physicians
• Multiple drugs may lead to adverse
reactions
Polypharmacy
• Most common adverse reaction in the
elderly is confusion
• Confusion in the absence of disease is
not normal!!
Nursing Interventions for
Polypharmacy
• Assess medications they are taking
• Encourage client to use one pharmacy
for all medications
• Encourage client to review with primary
caregiver all medications they are taking
Medication Noncompliance in the
Older Adult
• May be non-compliant due to:
–
–
–
–
Not understanding how to take medication
Forgetful
Don’t like the side effects
Don’t have the money to purchase
medications
Nutrition and the Older Adult
• Risk of nutritional problems increases
with age
• Energy needs decrease but nutrient
needs remain the same
Causes of Malnutrition in the Older
Adult
•
•
•
•
•
•
Loss of teeth
Digestive system changes
Loss/decrease of appetite
Lactose intolerance
Fixed income
Lack of socialization during meals
Nursing Interventions to Improve
Nutrition
•
•
•
•
•
Small, frequent meals
Assist with food choices
Identify causes of decreased appetite
Refer to dentist for teeth issues
Refer to social services for financial
problems
• Discuss ways to improve socialization
during meal time
Goals for Older Adults
• Follow therapeutic plan of care
– Ensure transportation to MD visits
– Ensure primary physician is aware of all
medications currently taking
• Maximize independence in self-care
activities
– Educate about resources to assist them with
care if needed
Goals
(continued)
• Maintenance of ability to communicate
– Educate about assistive devises such as hearing aids
– Assist with financial counseling to help pay for these
aids if needed
Goals
(continued)
• Maintenance of positive self-image
– Assist the patient to participate in appropriate
social activities to enhance the feeling of
worth
– Encourage open expression of concerns such
as feelings of hopelessness
Goals
(continued)
• Remain free of injury
– In the hospitalized patient
• Perform fall risk assessment
• Orient to surroundings and re-orient
as needed
• Provide assistance with ADL’s
Goals
(continued)
• Maintain bowel and bladder elimination
patterns
– Discuss nutrition to promote elimination
– Discuss use of medications if prescribed
– Urinary incontinence (loss of bladder
control) is a symptom, not a disease.
Goals
(continued)
• Maintain adequate nutritional status
– When hospitalized
•
•
•
•
•
•
Intake and output
Daily weight
Dietary referral for preferences
Socialization
Assist with feeding
Liquid supplements as needed
Goals
(continued)
• Maintain adequate fluid and electrolyte
status
–
–
–
–
–
Place water within easy reach of the client
Offer fluids every 1-2 hours
Monitor electrolytes
Intake and output
Administer and monitor IV fluids if needed
End-of-Life Issues
• Death and Dying
– Nurses must recognize influences on the
dying process
•
•
•
•
•
Legal
Ethical
Religious
Spiritual
Biological
– Provide sensitive, skilled and supportive care
End-of-Life Issues
(continued)
• Both the patient who is dying and the
family members grieve as they recognize
the loss
• Nursing Diagnosis of Anticipatory
Grieving includes:
– Denial
worthlessness
– Anger
concentrate
 Feelings of guilt
 Inability to concentrate
End-of-Life Legal Issues
• Medical Directive to Physician (Living Will)
– Addresses only the withholding or withdrawal
of medical treatment that would artificially
prolong life
– Becomes effective when the primary physician
and one other doctor say in writing that an
individual is in a terminal or irreversible
condition and that death will occur if lifesustaining medical care is not given
– Some states allow for personal instructions to
be added to this document
End-of-Life Legal Issues
(continued)
• Advanced Health Care Directive
– Used to be called Durable Power of Attorney
– An Advance Directive that allows an individual to
appoint representatives to make health care decisions if
they become incapacitated
– This document affects only health care and should not
be confused with granting power of attorney for other
matters
– Becomes effective when the person becomes terminally
ill or incapacitated.
Nursing Responsibility for Advance
Directives
• Each state varies; nurses need to be
aware of requirements for their state
• Be prepared to answer questions from
the patient about these directives
• Ask if your patient has these and make
sure copies are placed in their charts
• Advance Directives must be honored
End-of-Life Issues
(continued)
• Artificial Nutrition and Hydration is
another important ethical and legal issue
• Feelings about withholding food and
fluids are emotionally charged and often
have religious connotations.
• U.S. Supreme Court has upheld the right
of patients to accept or reject the
administration of artificial nutrition and
hydration.
End-of-Life Issues
(continued)
• Hospice Care
– Focuses on support and care of the dying
person and family
– Goal: to facilitate a peaceful and dignified
death
– Based on holistic concepts
• Improve quality of life rather than cure
• Support patient and family
Hospice Care
(continued)
• Principles of hospice care can be carried
out in a variety of settings
• Home and hospital are the most common
settings
• Palliative care: differs from hospice in that
the client is not necessarily believed to be
dying
Nursing Care of the Dying
Patient
• Provide personal hygiene measures
• Relieve pain
– Essential for patient to maintain some quality
in their life
• Assist with movement, nutrition,
hydration, elimination
Nursing Care
(continued)
• Provide spiritual support
– Arrange access to individuals who can
provide spiritual care
– Facilitate prayer, meditation and discussion
with appropriate clergy or spiritual advisor
Nursing Care
(continued)
• Support patient’s family
– Use therapeutic communication to facilitate
their feelings
– Display empathy and caring
– Educate family on what is happening and
what the family can expect
– Encourage family members to participate in
the physical care of the patient
Do Not Resuscitate
•
•
•
•
Also called DNR, No Code
Must be written
Must be reviewed regularly as per policy
May have specific requests
– Example: may okay vasopressors and fluids
but no chest compressions or intubation
Q&A?
This population ageing can be seen as a success
story for public health policies and for
socioeconomic development, but it also challenges
society to adapt, in order to maximize the health and
functional capacity of older people as well as their
social participation and security.