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PRINCIPLES OF GERONTOLOGY  The underlying core values and principles of geriatrics and gerontological nursing include 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 that 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 and 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. In the US, we often speak of “the graying of America,” but all nations are soon will be faced with important issues regarding the provision of healthcare to older persons.  In 1997, approximately 10% (561 million) of the world’s population was age 60 and older, and this level is projected to increase to 15% by 2025. LONGEVITY AND THE SEX DIFFERENTIAL  Prior to 1950, the male population outnumbered the female population.  In 1950, this trend reversed. Women comprise the majority of the older population (55%) in all nations and the majority of these women (58%) live in developing countries.  By 2025, nearly three quarters of the world’s older women are expected to reside in what is known today as the developing world.

The term feminization of later life describes how women predominate at older ages and how the proportions increase with advancing age. 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 such as tobacco, alcohol, and occupational hazards might negatively affect male life expectancy. LIFE AFTER 65  Women who reach the age of 65 can expect to live another 19 years, while men can expect to live another 16. This increase in life expectancy has been attributed to improved healthcare, increased use of preventive services and healthier lifestyles. THEORIES OF AGING SENESCENCE – refers to the progressive deterioration of body systems that can increase the risk of mortality as an individual gets older. Theories of aging fall into several groups, including biological, psychological, and sociological theories. • BIOLOGICAL AGING THEORIES


PROGRAMMED THEORIES – hypothesize that the body’s genetic codes contain instructions for the regulation of cellular reproduction and death.

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Programmed Longevity – aging is the result of the sequential switching on and off of certain genes, with senescence defined as the point in time when age-associated functional deficits are manifested. 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 – hypothesize that environmental assaults and the body’s constant need to manufacture energy and fuel metabolic activities cause toxic by-products may eventually impair normal body function and cellular repair. a. Wear and Tear Theory – Cells and organs have vital parts that wear out after years of use. A “master clock” controls all organs and that cellular function slows down with time and becomes less efficient at repairing body malfunctions that are caused by environmental assaults. b. Cross – Link Theory – an accumulation of cross-linked proteins resulting from the binding of glucose (simple sugars) to protein (a process that occurs under the presence of O2) 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. c. 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. d. Somatic DNA Damage Theory – Genetic mutations occur and accumulate with increasing age, causing cells to deteriorate and malfunction.

* PSYCHOLOGICAL AGING THEORIES 1. JUNG’S THEORY OF INDIVIDUALISM – Hypothesize that as the person ages, the shift of focus is away from the external world (extroversion) toward the inner experience (introversion).

The older person will search for answers to many of life’s riddles and try to find the essence of the “true self”. To age successfully, the older person will accept past accomplishments and failures. 2. ERICKSON’S DEVELOPMENTAL THEORY - According to Erickson, there are 8 stages of life with developmental tasks to be accomplished at each stage. - The task of the older adult includes ego integrity versus despair, - During this stage, 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. • 1. SOCIOLOGICAL AGING THEORIES DISENGAGEMENT THEORY Introduced by Cummings and Henry Asserts that the appropriate pattern of behavior in later life is for the older person and society at large 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 by proposing that older adults should stay active and engaged if they are to age successfully. When retirement occurs, replacement activities must be found. CONTINUITY THEORY Advances that 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.

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GERONTOLIGICAL NURSING ISSUES SCOPE of PRACTICE American Nurses Credentialing Center (ANCC) defines practice for the gerontological nurse as follows:  Gerontological nurses specialize in the nursing care and the health needs of older adults.  They plan, manage and implement health care to meet those needs, and evaluate the effectiveness of such care.  The nurse’s primary challenge is to identify and use the strengths of older adults and assist them in maximizing their independence.  Nurses actively involve older adults and family members as much as possible in the decision-making process, which has an impact on the quality of their clients everyday life. ADVANCED GERONTOLOGICAL NURSING

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Advanced Practice Gerontological Nurse (APRN) is an RN who holds a master’s, doctorate, or higher degree, and demonstrates advanced knowledge and clinical expertise in the care of the older adult. APRNs consist of Clinical Nurse Specialists (CNSs) and Nurse Practitioners (NPs) APRNs function independently and in collaboration with other healthcare providers in a variety of healthcare settings. Gerontological Nurse Practitioners (GNPs) deliver primary care to older clients and have considerable autonomy addressing healthcare problems, often with prescriptive authority. Focuses more attention on the direct provision and evaluation of care. Clinical Nurse Specialist (CNSs) provide direct and indirect care to patients and their families and serve as consultants to staff on complex issues of patient care. Focuses more attention on the educator and consultative role.

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Advanced practice nurses play an important role in caring for older patients by preventing, recognizing, and treating common problems and illnesses that are major causes of morbidity and mortality in the older adult. Advanced practice nurses also work with nursing staff to provide palliative care to dying patients by providing pain and symptom control. Once they have fulfilled with certification and licensure requirements, they may be authorized to prescribe medications, including controlled substances.

STANDARDS of GERONTOLOGICAL NURSING - describe the necessary competencies of care for each step of the nursing process. These are the essential foundation of the action taken by gerontological nurses when caring for their patients; to identify and meet the professional responsibility to deliver quality patient care to older persons. ANA Standards of Clinical Gerontological Nursing Care Standard I: ASSESSMENT. The gerontological nurse collects patient health data. Rationale – Interviewing, functional assessment, environmental assessment, physical assessment, and review of health records enhance the nurse’s ability to make sound clinical judgments. Assessment is culturally and ethnically appropriate. Standard II: DIAGNOSIS. The gerontological nurse analyzes the assessment data in determining the diagnosis. Rationale – The gerontological nurse, either independently or in collaboration with interdisciplinary care providers, evaluates health assessment data to develop comprehensive diagnoses that form the basis for care interventions. Standard III: OUTCOME IDENTIFICATION. The gerontological nurse identifies expected outcomes individualized to the older adult. Rationale – The ultimate goals of providing gerontological nursing care are to influence health outcomes and improve or maintain the aging person’s health status. Outcomes often focus on maximizing the aging person’s state of well-being, functional status and quality of life. Standard IV: PLANNING. The gerontological nurse develops a plan of care that prescribes interventions to attain expected outcomes. Rationale – A plan of care is used to structure and guide therapeutic interventions and achieve expected outcomes. It is developed in conjunction with the older adult, significant others, and interdisciplinary team members. Standard V: IMPLEMENTATION. The gerontological nurse implements the interventions identified in the plan of care. Rationale – The gerontological nurse uses a wide range of culturally competent direct and indirect interventions designed toward health promotion, health maintenance, prevention of illness, health restoration, rehabilitation, and palliation. The gerontological nurse implements the plan of care in collaboration with the older adult and others. The gerontological nurse selects intervention according to his or her level of education and practice. Standard VI: EVALUATION. The gerontological nurse evaluates the older adult’s progress toward attainment of expected outcomes. Rationale – Nursing practice is a dynamic and evolving process. The gerontological nurse continually evaluates the older adult’s responses to treatment and interventions. Collection of new data, revision of the database, alteration of nursing diagnoses, and modification of the plan of care are often essential. The effectiveness of nursing care depends on ongoing evaluation. ROLE by SETTING Gerontological nurses are employed in most healthcare settings. Approximately 60% of hospital patients, 80% of homecare patients, and 90% of nursing home patients are over the age of 65. Sites of care include:

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Skilled Nursing Facilities. Skilled care is delivered by nurses and others to residents. Care may be subacute or chronic for frail elderly residents requiring help with ADLs. Retirement Communities. Senior citizen retirement communities range in size and scope of services. Some are life care communities and offer coordinated independent living in apartments, assisted-living apartments, and nursing home care. Adult Day Care. Adult day care is an option for frail elderly people who require daytime supervision and activities. Residential Care Facilities. Called rest homes, these facilities are sometimes large private homes that have been converted to provide rooms for residents who can provide most of their own personal care, but may need help with laundry, meals and housekeeping. Transitional Care Units. Provide subacute care, rehabilitation and palliative care health services to patients who no longer require acute care. Most of these patients are recuperating from major illnesses or surgery, have complex health monitoring needs, or require palliative care with pain and symptom control.

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Rehabilitation Hospitals or Facilities. Special facilities exist to provide subacute care to patients with complex health needs. These patients may be head-injured or on ventilators, require aggressive rehabilitation after injury or surgery, or require the services and intensive treatments from specialists such as PT, OT, dietitians, and physiatrists. Community Nursing Care. The nurse may visit the patient on a regular basis to monitor VS, provide education or counseling, administer IM injections, change a dressing and deliver wound care, and provide supervision to home health aids or homemakers.

ETHICS - The ethical practice is guided by the Code for Nurses with Interpretive Statements (ANA, 2001) The gerontological nurse is concerned with the following ethical issues:  Obtaining informed consent for research and clinical treatment.  Obtaining, clarifying, and carrying out advance directives.  Appropriateness of emergency treatment  Provision of palliative care, including pain and symptom control, need for self-determination, quality of life, and treatment termination.  Elimination of the use of chemical and physical restraints  Patient confidentiality including electronic records  Surrogate decision-making  Access to complementary treatments  Fair distribution of resources  Economic decision-making - The gerontological nurse follows all ethical principles in the roles of clinician, advocate, case manager, researcher and administrator. Basic ethical principles include:

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Beneficence / Nonmaleficence. To do good and not harm patients. Justice. To be fair and distribute scarce resources equally to all in need.

Autonomy. To respect patients’ needs for self-determination, freedom and patient rights. Important aspects of Ethical Decision-making will include:

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ASSESSMENT. The older patient’s condition, including medical problems, nursing diagnosis, prognosis, treatment goals and treatment recommendations. RELEVANT CONTEXTUAL FACTORS. Age, education, life situation, family relationships, setting of care, language, culture, religion and socio-economic factors. CAPABILITY OF THE PATIENT TO MAKE DECISIONS. Legally competent, clearly incapacitated, diminished capacity, fluctuating mental status, presence of drugs or illness to cloud capacity. PATIENT PREFERENCES. Understanding of condition, views on qualityof life, values regarding treatment, and advance directives. NEEDS OF THE PATIENT AS A PERSON. Psychic suffering, interpersonal dynamics, resources and coping strategies, adequacy of the environment for care. PREFERENCES OF THE FAMILY. Competence as surrogate decision maker, judgment and evidence of knowledge of patient preferences, opinions on quality of life. COMPETING INTERESTS. Interests of family, healthcare providers, healthcare organization and futile utilization of scarce resources. ISSUES OF POWER OR CONFLICT. Between clinicians and family/patient, among family, among healthcare workers. OPPORTUNITY OF ALL INVOLVED TO SPEAK AND BE HEARD. Includes respect for opinions.

When an ethical dilemma arises in a clinical practice, nurses should begin an ethical analysis and communicate with colleagues to seek a solution. The process is a way to seek balance , address issues, and understand the needs of all involved.

COMMUNICATION Important to gerontological nurses Lines of communication must be clear to develop an appropriate NCP. Nurses need to communicate effectively with older patients with a variety of physical and cognitive impairments in order to develop a therapeutic relationship with each patient. Nurses should follow these guidelines for verbal communication:

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Do not yell or speak too loudly to patients. ( Not all older people are hard of hearing. If they are wearing a hearing aid, yelling can be disturbing) Try to be at eye level with the patient. (Sit down if the pt is sitting or lying down) Try to minimize background noise as it can make it difficult for the pt to hear. Monitor the patient’s reaction. Touch the patient if appropriate and acceptable. Supplement verbal instructions with written instructions as needed. Do not give long-winded speeches or complicated instructions to persons with cognitive impairment, anxiety or pain. Ask how the patient would like to be addressed. Avoid demeaning terms like sweetie, honey or dearie. An important part of communication involves attentive listening. Many times just the caring response and careful listening of the nurse will be a comfort to the patient. Encouraging reminiscing is usually fruitful – often gives comfort and reassurance to patients that they can talk about a time in their life when circumstances are better.


LEGAL ISSUES Older patients have the right to:  Receive individualized care.  Be free from abuse, neglect and discrimination.  Be free from chemical and physical restraints.  Have privacy.  Control their funds.  Be involved in decision-making.  Raise grievances and make complaints.  Vote.  File lawsuits.  Practice religion.  Marry.  Participate in facility and family activities.  Have freedom to leave the facility.  Make a will and dispose of property.  Enter into contracts. Nursing care that violates the standards of practice can be considered malpractice . The legal definition of standard of care is to consider what a reasonable nurse would do if placed in a similar situation according to professional standards. When the nurse performance does not meet the standards of care, malpractice can be charged.

Careful documentation of nursing care is the best way to defend oneself should a legal suit be filed. Charting should be legible, accurate, timely, and specific enough to describe the care given. PATIENT CONFIDENTIALITY Healthcare record and information regarding the care and treatment of the patient must be kept confidential. Pt have the right to view their medical record if they choose Pt have the right to ask questions regarding information contained in the record Pt can ask copies for their medical records – request granted in a timely manner Healthcare facilities must maintain medical records for at least 7 years. USE OF TECHNOLOGY IN ASSESSMENT Leads to additional problems with patient confidentiality and privacy. Computers should have passwords that limit access to authorized providers only. Patients must sign permission to authorize release of information before medical records can be copied, faxed, electronically transmitted, or released to others. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT HIPPA was signed into law with the broad goal of improving the efficiency and effectiveness of the healthcare system. The following healthcare information is considered confidential:  Patient identifying information (name, medical record number)  Health information relating to past, present or future health status or condition  Documentation regarding the provision of healthcare.  Past, present or future payment for the provision of healthcare INFORMED CONSENT AND COMPETENCE - The Patient Self-Determination Act requires providers to seek informed consent from all patients before they receive healthcare or engage in a research protocol. Older patients are entitled to be told the full implications of their treatment or nontreatment and then have the freedom to make an independent decision, without coercion, whether or not to receive the care Older persons have the right to make informed decisions about all care and treatment unless they have been determined to be incompetent (unable to make decisions) by a court of Law. Failure to receive consent before a medical or surgical procedure is carried out can be considered assault and battery; a criminal offense. To be considered capable of providing consent, older patients should have the ability to:  Comprehend information (understand)  Contemplate options (reason)  Evaluate risks and consequences (problem solve)  Communicate that decision (make their decision known) When a patient lacks decisional capacity because of severe illness, sedating drugs, or cognitive impairment: Living will, a healthcare proxy or surrogate decision maker, durable power of attorney, or involved family member – these persons or documents will be used to decide whether to proceed with the treatment or procedure. Lacks decisional capacity and has no predetermined wishes , family, or healthcare proxy – the care facility may seek a court-appointed guardian; may be relatives, friends or strangers. WARD – people with advanced dementia, untreated mental illness, developmental disabilities, head injuries, strokes, or long-standing drug addictions. END-OF-LIFE ISSUES

If a person has named a healthcare proxy to make a decision or has an advance directive such as a living will, then healthcare professionals will have guidance through the decision-making process at the end of life. DNR ORDERS may appear on the charts of many frail older patients. They are written and signed by the physician or advanced practice nurse and are legally valid orders. If a DNR order is not in place, then the older person should be a candidate for CPR (although, CPR is not very successful in older people who experience cardiac arrest) The gerontological nurse should consult the patient, the family and advance directives when a patient’s code status is being considered. All discussions with the patient and the family should be documented in the patient chart. If there are problems or disagreements within the family, the nurse should involve the social worker, clergy, or the ethics team.