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Pre-Midterm

Lakehead, Lakeheadu, Ti King, nursing, class, lab, holistic, personhood,


2050, 2250
2050 Class – look for the same lab below
Respect the fact that people are individuals with individual needs

← The Concept Of Personhood
← - The “self” (nursing care that respects and preserves the self in each
unique individual)
← - The “indomitable core” (nursing care that resects and preserves the
core of each unique individual)
← - “Beyond the body” (nursing care that goes beyond the body of each
unique individual)
← - “The story” (nursing care that recounts the story of each unique
individual)

← - Provide a holistic approach – taking into consideration psychology,
social health, physical health, spiritual health – take into consideration ALL
aspects of an individual.

← In order to know how persons ought to be treated, we must
know what makes them persons, and how as persons, they may be
harmed.

← To the world you might be on person; however, to one person
you might just be the world.

← We must look at the nature of human suffering as distinct from
physical pain.

← Dimensions Of Personhood
← - Physical
← - Psychological
← - Social
← - Spiritual
← - Functional
← - Broader context
← - Past, Present and Future
← - Mystery

← Failure to respect and acknowledge personhood makes the
already fragile person very vulnerable.

← Knowledge of the person is as important, if not more
important, than knowing the diagnosis.

← Such knowledge can help prevent unjustified decline.

← THE BODY DOES NOT EQUAL THE PERSON!

← Does your practice reveal that what your patient thinks and feels is as
important as his biological functioning?

← While we may know what is best for another person’s health,
we are arrogant if we assume we know what is best for another
person’s life.

← Much of the negative behaviour we see in persons may be the result of
depersonalization of them.

← Strategies To Honour Personhood:
← - Help people transcend their illness(es) and be themselves
← - Conduct holistic and knowledgeable assessment
← - Understand the person’s roles and encourage participation in those
that he/she can engage in
← - Promote relationships with significant others
← - Understand suffering as more than physical (ie/ both emotional and
physical)
← - Attend to the social environment
← - Provide comprehensive care (health promotion and health
protection/illness prevention, as well as cure and restoration)

← We need human relationships which help us break down the
distancing barriers in power relationships.

← A new philosophy underlies nursing education: Today we need a
far broader educational preparation for nursing than in the past. We have
moved from a task focus to a profession that includes: critical thinking,
problem solving (and problem finding), evidence-based practice and
research.

← Behaviourism restricted teaching to only that which was observable.
Therefore, we shifted our educational philosophy underlying nursing
education from behaviourism to humanism so that students can:
• Challenge their beliefs about themselves, and nursing
• Develop strong capabilities to reason through situations and find
ethical and safe solutions

← Why is nursing more complex today?
• Dealing with holistic needs of patients and families
• Going into communities to confront social and environmental issues
that affect health
• Greater emphasis on primary care, public health, and autonomous,
knowledge-based practice
• Patients are better informed (access to more knowledge, etc)
• A more complex environment technologically

← Overall, students will be more able to do the things that can have a
profound impact on clients and the health care system as a whole. For
example:
• Access, interpret and apply research knowledge better
• Advocate for clients better
• Negotiate the system
• Be change agents instead of ‘worker bees’
• Think and act more independently
• Better able to provide unique, individualized care to their clients

← Nurses will be knowledge workers, able to analyze and act quickly in
routine and unexpected situations.

← Be yourself – everyone else is taken.

← Concept:
• a person, place, thing, process, idea
← Model:
• Strings together concepts
← Theory:
• Helps to predict where we need to intervene
• Borrowed and unique

← The notion of holistic care

← The Concept Of Growth & Development

← Growth refers to increases in body size or change in structure,
function and complexity. It is overt (visible) and covert (hidden). It refers
not only to obvious changes in height and weight, but also to increase (and
in elderly persons, decrease) in the size of individual organs and systems. It
continues throughout the lifespan. It is also quantitative – we can measure it
(height, weight, lab work, body functions etc). Expected growth patterns
exist for all people (growth spurts, etc). The rate and pattern of growth can
be modified by intrinsic factors and by extrinsic factors – both before and
after birth. Although the limits of growth are genetically determined, illness
or environmental deficits may hamper a person’s growth.

← Development refers to changes in skill and capacity to function. It is
qualitative (hard to measure). It comes from a combination of maturation
and learning. A child cannot achieve maturity until physical growth is
complete. Developmentally maturity cannot be pinpointed at a particular
point in time.

← There are similar and predictable developmental patterns in early
development
• Simple to complex
• General to specific
o Grosser first, finer later
• Cephalocaudal (head to toe)
• Proximodistal (inner to outer)

← Early accomplishments in development are crucial to successful later
development.

← The Importance Of Understand G&D Throughout The Lifespan
Of The Person

← RNs need to shape his/her practice in response to client needs.
• Communication
• Assessment (child vs adult vs older adult for pain)
• Teaching (diagrams, how presenting, where presenting etc)
• Empowerment (strategies to boost confidence differ)
• Counseling
• And other care-interventions to promote, protect and/or restore
health

← People continue to grow and develop from conception until death.

← Adults experience normal transitions that are as necessary to their
continuing development as are the developmental landmarks of childhood.

← Growth and development are complex, interrelated processes. They
are influenced by and, in turn, can affect the health of an individual. Hence,
your need to shape your care in relation to the growth and development of
each client.

← Theories Of Aging

← Biological Theories Of Aging
• Genetic Programming/Biological Clock
o The study of having a predetermined life span (due to the
“clock”)
• Error Theory/Genetic Mutations
o Genes go wrong, mutations
o Growth can be stunted, or sped up etc
• Cross-linking
o Radiation, chemical rxn etc – DNA strands unable to split for
cell division (preventing mitosis – which can cause
organ/system failure)
• Free Radicals
o Highly reactive molecules (extra electrical charge)
o Produced by oxygen metabolism (constantly)
o If left unchecked, will begin to cause damage in the body –
proteins, enzymes
o Antioxidants fight free radicals (stop the chain of reaction) –
ie/ beta carotine, vitamin C & E
• Lipofuscin accumulation
o Lipoprotein (by product of oxidation)
o Seems to have a role (like free radicals) to accumulate over
time – may be correlation to age and how much you have
accumulated
o Interferes with transport of materials (ie/ metabolites),
exchange of information within the body
• Autoimmune reactions
o Autoimmune (when the body attacks itself)
o Ability to fight off infection/pathogens may be reduced in
older adults – so need to be extra careful
o Body can misidentify older cells – attack them, misinterpret
body cells as well
• Wear and tear
o Incremental injury over time
• Stress
o Spikes of acute stress are better than having chronic stress
(ability to deal with things)
 Hypertension, migraines, gut ulcers, gastric ulcers,
heart attack, inflammation of thyroid, skin diseases
• Disease
o Bacteria, fungi, viruses – how they can affect physiology with
aging
• Neuroendocrines (hormone) and neurochemicals
o Belief in anterior-pituitary that promotes aging
o Imbalance of chemicals in the brain and how it can affect
healthy cell division in the body
• Radiation
o Solar elastosis (changes in skin) – wrinkles (collagen reduces)
o Can produce a lot of mutations that promote aging
• Nutrients
o Obesity, diabetes, high blood pressure, heart disease
o Too thin
o Defiencies and excesses (cholesterol)
• Environment
o Changes in pH (inside body environment)
o Outside environment – mercury, pesticides, lead (smoking,
paint etc), noise/low vibration, crowded living conditions
• Apoptosis
o A mechanism of cell death that is distinct from necrosis
o Necrosis is an inflammatory response to trauma (injury,
pressure, cuts, bed sores etc).
 Characterized by uncontrolled breakdown of cell and
organ structure
 Cell swells, and membrane loses integrity (breaks)
o Apoptosis is a non-inflammatory, gene-driven process (not
trauma driven)
 Characterized by cell shrinkage and maintenance of
membrane integrity
 A normal development process that occurs continuously
throughout life
 When properly regulated, apoptosis is beneficial to the
organ because a balance is maintained between cells
that should be retained and those that should be
eliminated
o Longevity and senescence
 Centenarians
 Looking at genes, environment, activity, quality of life
(not just years), alcohol, sexual activity, diet, social
environment (a lot of determinants of health)
o Active life expectancy and functional health
 Health protection
 Insurance companies etx
o Medical theories
 Biogerontology – looks at links between aging and
disease

← Conclusions from biological theories of aging:
• It affects all living organisms
• It is natural, inevitable, irreversible and progressive with time
• The course of aging varies from individual to individual
• Rate of aging for different organs and tissues varies within
individuals
• It is influenced by nonbiologic factors
• It’s processes are different from pathologic processes
• It increases one’s vulnerability to disease

← The need to differentiate between aging and disease
• Primary aging
o Declines in physiological efficiency in all systems proceeding
from aging per se
o Leads to natural death
• Secondary aging
o Disease processes that may accelerate and hence mimic the
phenotype of primary aging but can be slowed down or
stopped through environmental, niomedical or behavioural
interventions

← Older age is not a disease and should not cause health problems such
as disability.

← Understanding the differences between aging and disease helps in
identifying interventions that can be used to prevent or delay the onset of
secondary aging processes.

← Sociological Theories Of Aging
• Disengagement Theory
o Not very popular anymore
o Suggests that when becoming older, should disengage from
society and quietly “go away” and do “whatever”.
• Activity theory
o Studying people who age well – what are they doing?
o Keeping active, physically, and in social roles etc
• Continuity theory
o To do with coping – strategies used while young are probably
the same ones used when older
o Coping can be healthy and unhealthy’
o Study same people over time
• Subculture theory
o Looking at older adults as a separate part of the culture
o Some view them similar in a lot of ways (values, beliefs,
habits etc)
• Age-stratification and age integration theory
o Looking a categories of people by age
o Talk about cohorts of people (by age)
o Cohorts may age differently due to different
views/experiences in life
o Generations being mixed together (age integration)
• Person-environment fit theory
o Looking at the person and environment – and how they
interact together (to see if environment is supporting, how
person can change to better cope with environment etc)
o Adapting to support function (cane story)
o Personal competence involves the following factors, which
collectively contribute to a person’s functional ability
 Ego strength
 confidence
 Motor skills
 Enhancing skills (physio, exercise etc)
 Biologic health
 Improving health
 Cognitive capacity
 Knowledge, learning/teaching
 Sensory-perceptual capacity
 Braile, hearing aid, seeing eye dogs, blister packs
for meds, techniques for reminding
o For each person’ level of competence there is a level of
environmental demand or press that is most advantageous to
that person’s function

← These theories attempt to explain how a society influences its older
person and how older persons influence their society.

← Psychological Theories Of Aging
• Human needs theory
o Maslow’s – motivation/needs
 Physiological needs, other categories etc
• Life span/life course theories and personality development
o People do things differently – instead of a stage notion
• Gender and aging theories
o Try to see if differences between genders – in communication,
thinking, emotions, health behaviors, expectation of
relationships etc

← These theories address questions about behavior and development
during later adulthood.

← Concept Of Family

← Families are contested political ground.

← Nuclear Family: Dad, Mom, Kids
• One parent working, duel incomes
• 2 parents, 1 parent, no children etc

← Adopted Family
← Foster Families
← Unmarried Teenage Mom
← Step-Parent Families
← Binuclear Families
← Gay/Lesbian Families

← Lay people are split as to how they view certain issues related to
family life. The split also manifests itself in the academic literature, although
it is usually more difficult to identify there. Thus, both popular writings as
well as scholarly writings are informed by different ideological positions
about family.

← Biases:
• Monolithic bias
o Families have uniform experiences and a universal structure
rather than diverse experiences and structures
o All couples go thru the same series of stages
o Problems are all structural
• Conservative bias
o primary changes are brief
o Either ignore or represent as very rare the ugly aspects of
family interactions that are, in fact, widespread
• Ageist bias
o Regard children only as passive members of families
o Regard older persons only as passive members of families
• Sexist bias
o Androcentricity – families should have a male perspective
o Paradoxical gynocentricity – ignore men in issues to do with
family (ignore their contribution)
o Gender insensitivity – ignoring sex/gender as an important
variable in situations where it is important
o Householdism – treat the family as a whole – and do not look
at the individuals (the family is the smallest unit – no look at
experiences of individuals etc)
o Double standards – evaluate things differently on sex (ie/
abuse of woman vs man)
• Microstructural bias
o Emphasize interfamilial or interpersonal variables and neglect
macrostructural variables
• Racist bias
o Assumption of the superiority of the family form seen as
typical for a dominant group
o Ignoring race and/or racism as a social variable in instances
where it is relevant
• Heterosexist bias
o The guy-girl relationship is the dominant one
o Ignoring the existence of lesbian and gay families
o Treating homosexuality as abnormal or pathological, and
hence treating lesbian/gay families as a abnormal and
problematic family form

← Cross Cultural Views Of The Family:
• Cross-cultural approach
o Culture includes:
 Ethnographic variables
 Nationality, ethnicity, language etc
 Demographic variables
 Statistics, census, population descriptors etc
 Status variables
 Socially, economically, education
 Affiliation variables
 Who the family hangs out with, link themselves
with – formal groups (political, religious), informal
(social groups) – web of connection
o Ethnicity:
 Group identity
 Shared social/cultural historys – values, norms,
customs
o Intra-ethnic variation
 Differences in the same ethnic groups
o Immigration
o Stereotyping
o Acculturation
 Moving away from one’s culture to another/dominant
culture
o Real versus the ideal
 How families adapt to different things
o Cultural relativism
 Understanding that people are who they are because of
how they live/contexts of their lives
o Ethnocentrism
 Belief in superiority of one’s own culture – and that
things should be done that way only
o Cultural imposition
 Forcing/imposing values on different people
o Cultural shock
o Indigenous health care systems

← Family Environment & Family Health
• Microsystem (or behaviour settings)
o Could be a home, street, wherever the family hangs out
o Immediate physical contexts in which face-to-face encounters
between family members and others occur
o Housing structure, safety and health hazards
o Resources in the home environment
o Homeless families
• Macrosystem (environment around)
o Educational system, work system, social service system
o Physical and geographic characteristics of the neighbourhood
and community
o Social and demographic characteristics of the neighbourhood
and community
• Suprasystems
o Include the national and global sociopolitical context for
macrosystem and Microsystems functioning
o Relevant sociopolitical and economic factors in the society
where the family lives

← Family Communication Patterns & Processes
• Channels of communications in families
• Functional communication processes
o Functional Sender
 Firmly and clearly states case
 Intensity and explicitness
 Clarifies and qualifies messages
 Invites feedback
 Is receptive to feedbacks
o Functional Receiver
 Actively and effectively listen
 Gives feedback
 Validates the merit or worth of the message
• Dysfunctional communication processes
o Dysfunctional Sender
 Makes assumptions
 Expresses feelings unclearly
 Makes judgmental responses
 Cannot define own needs
 Exhibits incongruent communication
o Dysfunctional Receiver
 Fails to listen
 Uses disqualification
 Responds defensively and negatively
 Fails to explore sender’s message
 Fails to confirm/validate messages
o Dysfunctional Sender & Receiver
 Communicate on different wavelengths (parallel talk)
 Are unable to focus on one issue
• Functional communication patterns:
o Communicating clearly and congruently
o Emotional communication
o Open areas of communication and self-disclosure
o Power hierarchy and family rules
o Family conflict and family conflict resolution

← Family Power & Decision Making
• Power:
o The ability – potential/possible or actual of an individual(s) to
control, influence, or change another person’s behaviour
• Family Power
o The ability – potential or actual of individual members to
change the behaviour of other family members
o Authority
o Power bases
 Legitimate power
 Helpless or powerless power
 Referent power
 Resource power
 Expert power
 Reward power
 Coercive power
 Informational power
 Affective power
 Tension management power
o Power outcomes
 Tells you where family power is
o Family decision making
 Consensus decision making
 Mutual agreement
 Accommodation decision making
 Compromise
 Bargaining
 force
 De facto decision making
 Power and balance

← Family Role Structure
• Two types:
o Formal family roles (explicit, overt)
 Marital roles/relationships
 Women’s and men’s roles in the family
 Grandparents’ roles in the family
 Family role changes
o Informal family roles (implicit, covert)
 Examples
 Scapegoat
 Go-between
 Labeling
• Variables affecting
o Social class differences
o Family forms
o Cultural/ethnic influences
o Family developmental stage
o Role models

← Family Values
• Nurses must respect ‘difference’ (demonstrate to families an
appreciation of, and respect for, different value systems)
• A system of ideas, attitudes and beliefs about the worth of a
concept that consciously and unconsciously bind together the
members of a family in a common culture
• More struggles come in the form of family values
• Values are learned from the family we originate one – steered in
certain directions
• Since the family is an open system, the family can be affected by
outside values
• Sometimes families buffer their values from other families as well
• Family values could respect/reflect societies values – or can have
values that respect/reflect their own subcultures
• Values can be shaped and changed
• When societal values change – has a large influence on families
(also: media, nutrition) – and they may or may not accept these
changing values (gate)
• When there is agreement/congruence between the families
subculture values and societies values it’s easier for the family to
adjust
• Families also have ideal/fantasy values, and then the real values

The greater the congruence between a family’s subcultural values and


the societal values, the easier the family’s adjustment and the greater
its success in relating to the community.

Families will often have values that they cannot realize –the real
versus the ideal

Sources of disparity in value systems:


-Diverse social values
-clash of values between the dominant culture and the subculture (the
family’s cultural reference groups)
-clash of values between generations
-clash of values between family members and the healthcare system
of providers in the healthcare system
Major Value orientations (dominate core values)
Such major values could affect
Society
Families
Family members
Health care
Health care providers
-individual achievement and productivity
-individual and independence
-Materialism/the consumption ethic
The notion of entitlement
-work ethic
-education
-equality
-Equity – is justice it is fair
-progress and mastery over the environment
-future time orientation
-efficiency, orderliness, and practicality
-rationality and reason
-quality of life and maintaining health
-tolerance of diversity

Affective Function
Deals with the internal functions of the family – The psychosocial
protection and support of its members
It is a means to achieve the family tasks of
Physical care
Reproduction
Teaching
Personal growth and development, bonding, and providing purpose
and meaning

The family assumes a heavy responsibility in meeting members’


socioemotional needs.

Family could contribute to


The stabilization of personality and behavior
The ability to relate intimately
The self-esteem of family members

← Sources Of Disparity In Value Systems (Conflict, Differences


etc)
• Clashes in social values
• Clashes between the dominant values in society vs values of the
subculture
• Clashes of values between generations
o Music, food, ways of being, respect
 Respect: We normalize things and when we stop
questioning we get into trouble – ie/ routine health
practices
• Clashes between the family member(s) and the health care provider

← Dominant Values Affecting Families


• Can cause angst (fear), pressure and grief
• Traditional values
o Holidays
• Notion of individual achievement
o One person in a family has a right to achieve; other members
push/support that person – causes problems
• Push for independence
o Thinking that you do not need anybody
• Materialism
o Also know as the consumption ethic (use, throw out, use
throw out etc)
o Everything needs to be new
• Work ethic
o Are we persons? Or robots?
o We tend to bureaucratize things
• Education ethic
o Education can come from many thing besides institutions
• Equality
o Treating everybody the same
o People are different – made up of difference resources, social
support systems, phases of life etc
o Equality smudges this and enables only simple
policies/system
o Different than equity
• Progress and mastery over the environment
o Develop land, build new hospitals etc
o Conflicts with people more involved in environmental issues
• Future time orientation
o Versus living for the moment
• Efficiency
o Keeping everything in order and thus efficient
o In health care known as managerialism
 Talks about cost, efficiency, time is of the essence
o Affects all institutions in society
• Rationality
o Everything needs to be scientifically proven
o Needs to be logical
o Need science to control nature/environment and health
• Quality of life and maintaining health
o Push for people to be more engaged in health protection and
promotion
o People running, walking, buying more nutritional foods,
McDonald’s changing menus
• Diversity
o People who want to know/understand it better – share in the
richness

← How Families Consider & Handle Health Issues
• Ways in which families view health are different
• Gender can affect health practices
o Can be in denial of health issues due to gender values
• Social class
o Can they take off time from work?
• Ethnic differences
o Deny things, not want treatments due to their views
• Beliefs of when to seek health care – level of alarm varies as well
o Traditional healer, relative, doctor etc
• All types of habits are different in families – food, activities,
shopping, drugs, self-care, environment (can be good or bad),
communication, health care prevention practices, use of alternative
therapies

Healthcare practices
-level of health illness
-birth control and conception issues
-family dietary practices
-family shopping, planning, and preparation
-family sleep and rest
-family exercise and recreation
-family therapeutic and recreational drugs
-family self-care practices
-family environmental and hygiene practices
-family alternative therapies

← Versions Of ‘Truth’ (ideologies (ideas), discourses (talk))


• There is no ‘one truth’
• They can compete/contest with each other that can cause fights,
wars, political wars
• In order to get a dominant truth to be the way it is, is done by the
use of power
• What happens when we don’t question what is taken for granted?
o You are throwing away your role
• These ‘truth’s are regimes – laiden with power (people struggle to
get the world they way they want it in order to meet their needs)
• Ideologies have winners and losers – they have motives, agendas,
claims behind them

← Marginalization: A Guiding Concept For Valuing Diversity In
Nursing Practice
• Can help us support personhood, peoples uniqueness and helps us
to look at the mess – and understand differences to help meet
health care standards in a better way
• Definitions:
o Margins: the peripheral, boundary-determining aspects of
persons, social networks, communities and environments
 They are established in many ways:
 In contrast to a central point
 According to separations they maintain between
the internal and external
 As distinctions between self and others
o Marginalization: the process thru which persons are
peripheralized on the basis of their identity associations,
experiences and environments,
o Marginality: the condition of being peripheralized on these
bases
• Marginalization may involve age, gender, racial, political, cultural,
economic, ability, and other forms of oppression


← Seven Key Properties of the Concept Of Marginalization:
• Intermediacy
o The tendency of human boundaries to act both as barriers
and as connections
o Interpersonal barriers may be obstacles as well as sources for
protection
• Differentiation (isolation)
o The establishment and maintenance of distinct identities thru
boundary maintenance
 ie. Gated communities
o Diversity can be stigmatized by the central ‘majority’ while
honored and celebrated by members of one’s group
• Power
o Influence exerted by those at the centre of a community over
the periphery and vice versa (mainstream, have advantages)
o When periphery come together as a group – can exert own
power that upsets the mainstream/centre, able to change
society
o Refers to the negative impact of domination as well as the
creative forces of coalition and solidarity
• Secrecy
o confining information to establish interpersonal bonds,
maintain trust and avoid betrayal
o Marginalized individuals may also keep secrets from
mainstream (ie/ no HIV, not pregnant, etc) – therefore must
establish trust with these individuals
o Can work other way as well – mainstream holding secrets (ie/
infection rates, drug errors) and not reporting to public
(parallels with power)
o Involves fear of betrayal and exclusion via tight interpersonal
bonding, yet also preserves trust and a sense of belonging
• Reflectiveness
o The fragmenting and conflicting psychic effects on
marginalized persons of discrimination, privatization,
isolation, invisibility and fragmentation and the interior work
that is required to understand and compensate for these
effects
o Thinking and trying to make sense of when you have been
marginalized
o Reveals how social processes cause internal fragmentation,
and awareness that can be demoralizing or empowering
depending on whether there is adequate support from others
• Voice
o The languages and forms of expression characterizing
marginalized subcultures
o Voice encompasses types of talk (ie/ mixed talk, back talk,
new talk) and ways of telling (ie/ narrative)
o Hearing people’s stories
o Carries implications of being silenced and misunderstood as
well as the possibility for positive, powerful expression
• Liminality
o Altered and intensified perceptions of time, worldview, and
self image that characterize and result from marginalizing
experiences
o Marginalization has a liminal quality in that it carries crucial
consequences for human development, maintenance of self-
esteem, health promotion and restoration
o Coming to the conclusion
o Characterizes experiences that are often filled with danger
and yet may be invaluable opportunities for change and
insight

← Marginalization on the external level can affect race, appearance,
ability etc. On the other end, practices such as smoking, religion,
occupation, sexual behaviours can be subjected to marginalization as well.
In addition, cultural identity can be affected as well, also political views,
illnesses, economic class. These are all axis of difference – gaps in society
where people fall and disappear. This happens in health care.

← Exploring the properties of marginalization exposes the linkages
between vulnerability and health for those living at the edge of society and
suggests that the health consequences of marginalization experiences result
not only from the perception of marginalized persons, but also from
contingencies of their environment.

← Vulnerability is the condition of being exposed to or unprotected from
health-damaging environments. It has both negative and positive
implications:
• Risk is the increased potential for developing illness as a result of
disproportionate exposure to damaging environmental factors
(negative)
• Resilience incorporates capacities gained from person-environment
interactions that foster survival (positive)
o Allows us to think things through better, understand the
politics etc
o It includes genetic predispositions and learned abilities of
persons and, as well, factors in their surroundings that
enhance their well-being
o There is significant variability in resilience among
marginalized persons across adverse circumstances

← Each of the properties of marginalization carries elements of risk and
resilience that have health consequences (see key properties).

← RNs who do not know the health-related responses of marginalized
persons may be inadequate in understanding and addressing problems
stemming from social alienation, economic deprivation and political
repression.

← The struggle for marginalized persons focuses on their needs for:
• Access to health resources
• Political and economic resources to ensure their basic needs
• The social legitimation and respect necessary to make decisions
affecting their health

← Marginalization provides a unique lens through which to view and
understand the health and health care of diverse populations.

← Marginalization impresses on us our need to approach members of
marginalized groups with an ear to their experiences and an eye to their
struggles.

← One key research strategy is to invite marginalized persons to talk at
length about the health problems they face, the obstacles that block their
access to health care and other resources, and what they think they need to
remedy their situations.

← This is rarely done in research or practice in any discipline.

← ****POST MIDTERM NOTES****





Young Adults 14/04/2010 11:14:00
← PSYCHOSOCIAL DEVELOPMENT IN YOUNGER ADULTS

← Important to study this to be able to work with younger adults
appropriately.

← Cognitive Development
← Becoming mature in young adulthood involves:
• Intellectual growth
• Becoming more adaptive and knowledgeable about self
o More able to role situations
• Forming values
• Developing increasing depth in analytic and synthetic thinking,
logical reasoning and imagination

← The many different intelligences include:
• Academic aptitude
• Leadership ability
• Creative and performing arts abilities
• Ability to manage self, others and a career

← Developing social and interpersonal skills and personal friendships may
have a powerfully maturing affect on intellectual skills.

← Influences on learning include:
• Level of knowledge in society generally
• Personal values and perceptions and previously learned associations
• Level of education (also: where you got it, and from whom)
• Available life opportunities (chances and choices)
• Interests
• Participation by the learner
• The learning environment
• Life experiences

← Developmental Impact of Post Secondary Education
• People who acquire a degree:
o New socialization opportunities
o Advances in moral and social reasoning
o Increased ability to empathize with others
o An income advantage (more promotions, less unemployment,
higher status etc)
o More likely to get high status positions
o Viewed as more desirable employees
o Have better performance on formal operations and other
measures of abstract reasoning

← During their post-secondary education, students’ academic and
vocational aspirations change.

← Thus, it is critical that such education enables students to make
realistic assessment of their academic abilities.

← Relationships among authoritative parenting, academic performance
and social adjustment prior to entering post-secondary education, seem to
be critical to a student’s ability to benefit fully from the educational
experience.

← Some Characteristics of Formal Operations Thought:
• Creative in thought
• Begins at the abstract level: compares ideas with previous
memories, knowledge, or experience
• Mentally integrates many steps of a task, instead of thinking about
or doing each step as a separate unit
• Considers the multiplicity and relativism of issues and alternatives
to a situation, so the end result is a unique solution
• Can differentiate among many perspectives
• Is ‘objective’, realistic and less egocentric-thinking and learning are
problem-centred not just subject-centred
• Reality is considered only a part of what is possible; they can
imagine and reason about events that are not occurring in reality
but are possible
• The thought system works independent of context and can be
applied to diverse data
• Can evaluate the validity of a train of reasoning independent of its
factual content
• Generates hypotheses; makes deductions and observes to
disconfirm expectations
• A concrete proposition can be replaced by an arbitrary sign of
symbolic logic (ie/ p or q)

← Some theorists dispute Piaget’s idea that formal operations is the last
stage of cognitive development.

← These theorists suggest that normal problems of adult life, with their
inconsistencies, complexities, uncertainties and paradoxes, cannot always be
addressed well using formal operational logic.

← Thus, they propose new structures or new stages of thinking in
adulthood:
• Contextual Validity
o In this context, is it true? Does it work in the immediate
surroundings?
o Thinking skills are specialized and pragmatic (ie/ how to solve
problems associated with roles or jobs they hold)
o Thus, they trade deductive thinking (of formal operations) for
contextual validity
o Situation specific
• Dialectical Thought
o Whereas formal operations involves trying to find
fundamental fixed realities (basic elements, and immutable
laws)
o Talking to people to understand complexities, mess etc
o Dialectical thought attempts to describe processes of change
• Postformal Thinking
o Whereas formal operations involved problem solving, some
adults develop a further stage characterized by problem
finding
o This mode involves creativity
o It is effective for dealing with problems that do not have clear
solutions or problems with multiple solutions
o Only a small number of adults achieve this stage

← Emotional Development

← Love: the feeling of accompanying intimacy.

← Love and intimacy change over time.

← By the mid-20s, the person should be experienced in the emotion of
love.

← If there was deprivation or distortion of love in the home when s/he
was younger, the adult will find it difficult to achieve mature love in an
intimate relationship.

← By this time, the person should realize that one DOES NOT FALL in
love; one LEARNS TO LOVE & GROWS TO LOVE.

← Moral Development

← This is one of the grey areas that is very pertinent to nursing.

← The YA may be in either the CONVENTIONAL LEVEL or the
POSTCONVENTIONAL LEVEL of moral development (pg 222-223).

← There are two stages to the conventional level (the most common in
adults):
• Stage 1
o Decisions and behaviour are based on concerns about others’
reactions
o Social groups, organizations, places of work etc
o Is capable of empathetic response
• Stage 2
o Obeys the law because it is the law or because respects
authority and the underlying morality of the law
o Social systems, government etc

← There are two stages to the postconventional level:
• Stage 1
o Adheres to legal views of society
o However, believes laws can be changed and people’s needs
change (general as well as relativistic)
o Can transcend views about social order and develop universal
principles about justice, equality and human rights
o “I’ll do something because it is morally and legally right, even
if it isn’t popular with the group”
• Stage 2
o Still operates as in stage 1 but incorporates injustice, pain
and death and an integral part of life
 A much more universal focus
o “I’ll do something because it is morally, ethically and
spiritually right, even if it is illegal and I get punished and
even if no one else participates in the act”

← Self Concept & Body Image Development

← The person’s perception of self – physically, emotionally and socially –
is based on the following:
• Reactions of others (ie/ family, place of employment) that have
been INTERNALIZED
• Self-expectations
o Expectations we have put upon ourselves
• Perceived abilities
o Realistic or not?
• Attitudes
o Our self talk, how we talk to others, words
o What we say, does matter.
• Habits
• Knowledge
• Other characteristics

← A person’s behaviour depends on:
• Whether s/he feels positively or negatively about self
• Whether s/he believes others view him/her positively or negatively
• How s/he believes others expect the person to behave in this
situation

← A person discloses aspects of self depending on:
• Needs
• What is considered socially acceptable
• Reactions of others, and
• Past experience with self-disclosure

← Body image: a part of self-concept – a mental picture of the body’s
appearance

Body image includes:
• the surface, internal and postural picture of the body and
• values, attitudes, emotions and personality reactions of the person
in relation to the body as an object in space, separate from others

← Body image is flexible and subject to constant revision.

← Body image in the adult is a social creation.

← Normality is judged by appearance, and ways of using the body are
prescribed by society.

← Approval and acceptance are given for ‘normal’ appearance and
‘proper’ behaviour.

← In the adult, there is close interdependence between body image and
personality, self-concept, and identity.

← REFER TO PHOTOCOPIES FOR MORE NOTES ON YA’S.

Middle Aged Adults 14/04/2010 11:14:00
← PSYCHOSOCIAL CONCEPTS IN MIDDLE-AGE

← Most studies in adult cognition have been cross-sectional (vs
longitudinal).

← Thus many factors, other than age, have influenced results. Such
factors include:
• Amount of education
• Different experiences
• Fixed attitudes
• Number of years since finishing formal school
• Health status
• The kind of test given
• Speed requirements

← IQ tests may be irrelevant.

← Instead, we should test how people identify problems and use reason
and intuition to solve them.

← Some Information About Cognitive Development In Middle Age

← Reaction time or speed of performance:
• Studies suggest that it stays the same, or could diminish a bit
(however in late middle age, normal aging changes begin to occur)

← Memory:
• Some people have found no major differences

← Learning:
• Occurs in people of all ages
• People who are highly intelligent become more of a learner
• Capacity for intellectual growth should be unimpaired

← Problem-solving abilities:
• Ability should remain intact
• Use’s Piaget’s stage of formal operations (pg 221)
• Sometimes uses concrete operations for practical reasons (pg 220)
• Also uses post-formal thought (problem finding)
• Many patterns mark the development of intellectual skills:
o Represents experience symbolically
o Reflects on experience
o Imagines, anticipates, plans and hopes
o Develops an inner private world
o Recalls
o Monitor thoughts
o When solves a problem, can explain how (can give rational)
o More imaginatively productive
o Increasingly interested in other people and relationships
o Adaptable, independent, self-driven, conscientious,
enthusiastic and purposeful
o Reflects about personal relationships and thus understands
why other people feel and act as they do (empathy)

← Adult thought is characterized by dialectical thinking:
• Seeks intellectual stimulation, even crisis
• Welcomes contradictions and opposing views
• Creates a new order and discovers what is missing
• Struggled with morality, ethics, philosophy, religion and politics

← Creativity:
• People are less productive in total creative output in their 20s then
they are in their 30s and 40s
• Creativity is seen not only in famous people, but also in how people
approach situations, tasks and learning

← Continued learning:
• MA persons are frequently involved in continued learning
• Teaching methods that capitalize on learning strengths of mature
adults include:
o Active discussion and role play
o Help them to interpret, integrate, apply, analyze and
synthesize knowledge
o Validate with them that they can learn
o Environment conducive to learning (ie/ consider
environmental changes – normal aging changes)

← Work & Leisure

← Work is viewed differently by different middle-agers (ie/ older vs
younger)

← New categories of workers (different from the past)
• Free agents
• nomads
• Globalists
• Niche-finders
• Retreads
o Never without job and always learning/self-improving
• Corporate leaders
o New age bosses

← The time spent at the full-time job has increased over the past 20
years leading to a decline in leisure and in private life.

← Ways in which we are connected to work:

← Many MA women work outside the home; thus, they are ‘in the middle’
(sandwiched) in terms of demands on their time and energy

Emotional Development

A period of self-assessment and greater introspection


• Thinking inside
Appraises how achievements measure up against goals and values
• How are we doing against the benchmarks against us?
• What is the reality – how does my fantasy measure towards it?
Realizes past choices limit present choices and time is finite
• Regrets and realizations

Developmental crisis (Erikson): generativity vs self-absorption and


stagnation

Generativity: concern about providing for others that is equal to the concern
of providing for self

Characteristics:
• A sense of parenthood and creativity; of being vital in establishing
and guiding the next generation, the arts, or a profession; of feeling
needed and being important to the welfare of humankind
• The self seems less important
• The concepts of service, love of others, and compassion gain new
meaning and motivate action
• A sense of comfort in lifestyle, gratification from a job well done
and from what has been given to others
• Accepts the self and body (aging)
• Deep sincerity, mature judgment, empathy
• Values give stability and cause the person to be reflective and
cautious

Stagnation/self-absorption: regresses to adolescent, or younger behaviour,


characterized by physical and psychological invalidism

← Characteristics:
• Hate the aging body
• Feels insecure and inadept at handling self (physically and
interpersonally)
• Impaired and less socially organized intellectual skills and values
• Intellectual skills are fused by personal emotions
• Seeks private self-absorption and vicarious immersion in problems
of others
• These methods of coping may or may not work well
• Consequences (pg 634)

← Maturity: maturity is not a quality reached at any one age for all time

← Characteristics:
• Fully developed as a person (holistic)
• Doing what is ‘appropriate’ for age, situation and culture
• Reflective – restructures or processes information in light of
experience uses knowledge and expertise to achieve desired ends

← Staying power is part of maturity:
• Characteristics of staying power:
o Integrity
 Let’s not just fix it – but do it the right/fair way
o Loyal to values, faith, philosophy, beliefs
o Holds to a cause greater than self
o Gives up something worthwhile, rather than worrying about
present risks

← In adulthood there is no one set of ‘appropriate’ personality
characteristics.

← Criteria of emotional maturity (p 635 box)

← Moral Development In Middle Age

← Moral development is advanced whenever the person has an
experience of sustained responsibility for others. Middle age, if lived
generatively (opportunities for caring for other people) provides such an
experience.

← Consistent commitment to ethical application of higher principles.
Level of COGNITIVE development sets the upper limits for MORAL potential
(thus, if adult remains in concrete operations, s/he will unlikely move
beyond conventional level of moral development [law & order reasoning]
because postconventional level requires indepth understanding of events,
along with critical reasoning ability).

Aging & Changes
“Age is a convenient index to group phenomena, but it does not
reflect the dynamic processes that bring about the changes
associated with age”

← LIFE TRANSITIONS
← Various changes during the aging process demand multiple
adjustments that require stamina, ability and flexibility.
• Role changes
o Losing a child, divorce, becoming a grandparent
• Ageism
o Marginalization against age
• Grandparenting
o Divorce ruining relationships – getting rights
• Widowhood
• Retirement
• Awareness of mortality
• Declining function
o Some adapt differently
o Normal aging changes
o Disease
• Reduced income
• Shrinking social world

APOCALYPTIC DEMOGRAPHY
While we should not discount the social importance of population aging we
should not overemphasize it either.

Some people attempt to overemphasize it through a discourse/ideology


referred to as apocalyptic demography (or voodoo demography).

Apocalyptic Demography:
• Used to characterize the oversimplified notion that a demographic
trend – in this case, population aging – has catastrophic
consequences for a society
• Consists of 5 interrelated themes
o The negative portrayal of aging as a social problem that
needs fixing
o The homogenization of older persons – stereotyped
o Age blaming – blaming older adults for overusing social
programs and, therefore, for government debt/deficits
o Intergeneration injustice – older people are getting more than
their fair share of societal resources leading to severe
intergenerational conflict
o Intertwining of population aging and social policy (ie/ social
policy guided by deep cuts in order to accommodate the
growing number of older adults. Dismantle the welfare state
to counteract the societal burden of an aging population

← Evidence of attempts to dismantle:
• Attempts to privatize pensions
• Attempts to eliminate Old Age Security
• Attempts to reduce health care spending (and associated
privatization)

← Iatrogenic illness (aka unintended harm) – very big concept.
• Refers to all clinical situations in which our treatment/care,
physician care, and conditions – are harmful.
• Examples:
o The wrong drug (many drugs contraindicated, knowledge
about this is essential – or you are setting up for harm)
o An old drug
o A contaminated drug
o Interactions with drugs
o Antibiotics (superinfections)
• A lot of this is contributed due to system breakdown

← Adverse Events (AE) defined:
• Unintended injuries or complications that result in death, disability
or prolonged hospital stay that arise from health care management

← The researchers selected 4 hospitals in each of 5 provinces (BC, AB,
ON, QB & NS) and randomly reviewed charts for the year 2000. The results
indicated the AE rate being 7.5 per 100 hospital admissions. Among the
patients with AEs, events judged to be preventable occurred in 36.9% and
death in 20.8%. It was estimated that 1521 additional hospital days were
associated with AEs. The patients that had these AEs were significantly older
than those who did not. The overall incidence rate of AEs of 7.5% in our
study suggests that, of the almost 2.5 million annual hospital admissions in
Canada similar to the type studied, about 185 000 are associated with an AE
ad close to 70 000 of those are potentially preventable.

← In 2002, the Canadian government created the Canadian Patient
Safety Institute and many health care organizations have initiated efforts to
improve patient safety.

← FACTORS THAT MAKE OLDER ADULT CARE A COMPLEX
UNDERTAKING
← - Older adults’ great diversity/uniqueness
← - Other factors (ie/ few finances or social isolation) affect their health
and wellbeing
• Depression is very prevalent among older adults
← - Unique and complex relationships between normal aging changes,
and effects of disease and other abnormal conditions (ie/ effects of drugs
and other treatments)
← - Most have chronic conditions that uniquely affect acute illnesses,
reactions to treatments and quality of life
← - The causes of illness are more variable
← - Symptoms are physical diseases frequently overlap with symptoms
of psychological disease
← - Many older adults tend to underreport symptoms
← - The manifestations of illness, even acute illness, tend to be subtler
(vague and less visible) and less predictable in older adults. For example:
• Heart attack diagnosis
o Absence of pain
o Pain may radiate into left arm, neck and abdomen
o May become confused
o Low grade fever
• Older adults are likely to experience changes in their level of
functioning as manifestations of physiologic disturbances or adverse
medication effects
• An older adult with infection is much more likely to have mental
changes rather than an elevated temperature (also important to
know an older adults normal baseline temperature – could be
different than 37)
o UTIs affect 1 in 10 older adults making it the most common
infection among this population
 Early S&S include:
 Burning on voiding
 Urgency (need to go now)
 Might have fever
 Incontinence
 Confusion
 Septicemia (blood poisoning)
o Pneumonia
 May not exhibit chest pain
 Fatigue
 No cough
 One of the leading causes of death
o Influenza
 More susceptible due to depressed immune system
 May not exhibit fever
 Secondary infections can occur as well
o MI or ulcer
 Can be missed
 Absence of pain

← Multiple health conditions can coexist and muddle the ability to chart
the course of a single disease, or to identify the underlying causes of
symptoms.

← The risk for complications is high.

← Older adults may have multiple complaints, due to multiple coexisting
diseases.

← For any manifestation of illness in an older adult, there are usually 3
possible explanations. For example, changes in function (cognitive, physical
etc) are usually related to a combination of several of the following:
• Acute illness
o Pneumonia, heart failure
• Psychosocial factors
o Depression
 Can happen from disease, drugs, life situations etc
• Environmental conditions
• Age-related changes
• A new chronic illness
o Diabetes
• An existing chronic illness
• An adverse effect of medication(s) or other treatments
o May be prescribed, self-prescribed, complementary,
alternative etc)

← Clinical Status:
• Hydration
• Nutritional status
• Daily practices
• Diseases

← Diagnoses often do not tell the whole story. Therefore it is more
helpful to think in terms of PRESENTING PROBLEMS. Common problems in
older adults include:
• Immobility
• Instability
• Incontinence
• Intellectual impairment (confusion)
• Infection
• Impaired vision/hearing
• Irritable colon
• Isolation (depression)
• Inanition (malnutrition)
• Impecunity (little or no money)
• Iatrogenesis
• Insomnia
• Immune deficiency
• Impotence

When older adults are depressed, cognitively impaired, or otherwise


psychosocially compromised, assessment of a physiologic illness becomes
even more difficult.

By the time illness in an older adult is identified and attended to, the
underlying physiologic disturbance may be in an advanced stage, and
additional complications may have developed.

The consequences of illness:


• Are more far reaching (likely to have an increased impact on the
older adult)
• And they may combine with other factors to compromise the
person’s functional status and quality of life
• And there may be serious psychosocial consequences of illness

← Health care professionals lack knowledge about:
• The unique manifestations of aging and of disease
• Relationships between disease and age related changes
• How to assess and treat common geriatric conditions accurately and
effectively
• The interplay between chronic and acute conditions and normal
aging changes and effects of treatments (ie/ drugs, adverse drug
reactions, diagnostic tests etc)

← The elective status of gerontological care in many nursing and medical
schools can limit the number of health care professionals who are
knowledgeable about the unique aspects of caring for older adults.

← For all these reasons, assessment of illness in older adults:
• May require a detective-like approach
• It is a time-consuming and puzzle-solving process
• If shortened, it can end up harming the older person

← Gerentological nurses have an important role in advocating for policies,
systems, programs and care practices that recognize the complexity of older
adult’s needs and care.

← Conditions that older adults experience can cut across many clinical
specialties, thereby challenging gerontological nurses to have a broad
knowledge base.

← Older adult care requires:
• Shared goals amongst gerontologically prepared health care
professionals
• Broad models for care
o Not just medical model – health promotion and protection as
well
• Effective communication
• Effective coordination of care
• Effective continuity of care

← We cannot classify care into clear and simple categories – and no one
profession has all the answers (requires interdisciplinary care).

← CONFUSION IN OLDER ADULTS

← Confusion is NOT normal. It can happen to anybody, at any age. Due
to normal aging changes though, older adults are more at risk. Causes of
confusion can kill people and/or cause permanent damage to an individual.

← Old age alone does not cause impairment of cognitive function of
sufficient severity to render a person dysfunctional.

← Appropriate diagnosis and management of older adults exhibiting
symptoms and signs of confusion can make a critical different to their overall
health and ability to function independently.

← The major causes of confusion in older adults are delirium and
dementia.

← Prevalence in acute care and in nursing homes – between 25-50% of
older adults are delirious on admission (acute care) or developed it during
time spent in hospital. In nursing homes, 50-80% have a cognitive
impairment.

← Misdiagnosis and inappropriate management of syndromes causing
confusion in older adults can cause substantial morbidity, even death,
hardship to families, and millions of dollars in health care expenditures.

← ISSUES ABOUT LANGUAGE: DEFINITIONS & TERMS

← Some definitions of the term ‘confusion’ are too broad and imprecise to
be clinically useful. Similarly, terms like ‘confused’ and ‘confused at times’
are imprecise.

← Descriptions such as “impairment of mental function” or “cognitive
impairment”, along with careful documentation of the timing and the nature
of specific abnormalities, provide information that is more precise and
clinically useful.

← Such documentation is best accomplished by means of a thorough
mental status examination.

← MENTAL STATUS EXAMINATION

← Several basic components are essential in diagnosing dementia,
delirium or other syndromes.

← Assess:
• Orientation
o Who they are? Where they are? What time/date it is?
• Memory & Retention
o Short and long term
• Abilities to follow commands
o Ie/ draw a triangle
• Judgment & Reasoning
o Ie/ the lady who put her hand into a boiling pot of water (to
get out the food)
• Calculation
• Problem solving
• Executive control
o How a person plans/sequences a task
• Level of consciousness
o Are they alert? Changes?
• General appearance
• Mood
• Speech
o Coherent? Rambling? Well-rehearsed stories?
• Perception
o See, hear, feel, smell etc (use of senses)
• Proverb interpretation

← When testing people always consider the following:
• Unique experiences
• Educational level
• Cultural background
• Sensory deficits
• Implications of health challenges
• Stress associated with being examined

← TOOLS USED TO ASSESS COGNITIVE FUNCTION

← Short Portable Mental Status Questionnaire
← Philadelphia Geriatric Centre Mental Status Questionnaire
← Mini-Mental Status
← Symptoms Checklist 90
← General Health Questionnaire
← OARS
← Zung Self-Rating Depression Scale

← Thus, scores on one or more of these tests should not be used to
replace comprehensive examination of all the components.

← DIFFERENTIAL DIAGNOSIS OF CONFUSION

← The causes of confusion in older adults are myriad (multiple).

← As with other disorders in older adults, confusion often results from
multiple interacting processes rather than a single cause.

← Disorders causing confusion in older adults can be broadly categorized
into three groups:
• Acute disorders
o Infection, dehydration, heart problems, diabetes
o May be the first sign we get
• Slowly progressive impairment of cognitive function
• Impaired cognition associated with affective disorders and
psychoses

← Remember, old age alone does not cause impairment of cognitive
function of sufficient severity to render a person dysfunctional.

← Potent clinical labels and risks of premature closure.

← Three questions are helpful in making an accurate diagnosis of the
underlying cause(s) of confusion:
• Has the onset of abnormalities been acute?
o New medication, electrolyte imbalance, dehydration
• Are there physicial factors that may contribute to the
abnormalities?
o Treatments, disease, blood work, medications
• Are psychological factors contributing to or complicating the
impairments in cognitive function?
o Progressive dementia, delirium, depression (all from many
causes – all happening in the same person)

← These questions may help to identify causes that are fixable (as
opposed to non-fixable issues).

← DELIRIUM

← Known as acute confusion – often is fixable.

← Key features include:
• Disturbance in consciousness
o Not a sign of dementia, zoning out, fluctuating etc
• Change in cognition not better accounted for by dementia
• S&S developing over a short period of time (hours to days)
• Fluctuating signs and symptoms
o May be with you one moment, then not the next moment
• Evidence that the disturbances are caused by the physiological
consequences of a medical condition

← The disturbances of consciousness and attention, with the suddenness
of onset and the fluctuating cognitive status are the major features that
distinguish delirium from other causes of impaired cognitive function, like
dementia.

← SIGNS & SYMPTOMS:
← Onset of symptoms tend to be rapid, and can include:
• Disturbed intellectual functioning
o Drug, medication etc
• Disorientation of time and place, but usually not of identity
• Altered attention span
• Worsened memory
• Labile mood
o Moodswings (happy then sad, etc)
• Meaningless chatter
• Poor judgment
• Altered LOC, including:
o Hypervigilance
 Busy
o Mild drowsiness
 Quiet
o Semicomatose status
• Disturbances in sleep-wake cycles can occur; in fact, restlessness
and sleep disturbances may be early clues
• May be suspicious, have personality changes, and experience
illusions (need a stimulus, misinterpret) more often than delusions
(no stimulus, hallucinations)
• Physical signs, such as shortness of breath, fatigue, and slower
psychomotor activities, may accompany behaviour changes

← Delirium alters levels of consciousness, whereas dementia does
not!

← POTENTIAL CAUSES OF IMPAIRED COGNITION

← Fluid and electrolyte imbalance
← Medications (monitor new ones especially)
← CHF
← Decreased cardiac function
← Hypotension – heart not beating enough, too much antihypertensive
← Hyperglycemia and hypoglycemia – diabetes
← Hyperthermia and hypothermia
← Hypercalcemia and hypocalcemia
← Hypothyroidism
← Decreased respiratory function – conditions (croup, obstruction,
bronchitis, asthma), gas exchange problems (pneumonia, etc) and transport
(hemoglobin issues)
← CNS disturbances
← Emotional stress
← Pain
← Malnutrition
← Dehydration
← Anemias
← Infection
← Trauma – burns, hit on the head
← Malignancy – cancers
← Alcoholism
← Hypoxia
← Toxic substances

← Rapid recognition of delirium is critical because it is often
related to other reversible conditions and its development may be a
poor prognostic sign for adverse outcomes including nursing home
placement and death.

← Other key points to consider:
• It’s also important to differentiate delirium from dementia because
dementia is not immediately life-threatening, and inappropriately
labeling a delirious patient as demented may delay the diagnosis of
serious and treatable conditions
• The diagnosis of dementia must await the treatment of all
potentially reversible causes of delirium
• People can have depression from one of more causes, delirium from
one or more causes, and dementia from one or more causes, all at
the same time

← DEMENTIA(S)

← Key features include:
• A gradually progressing course
o Insidious
• No disturbance of consciousness

← Dementia in older adults can be grouped into two broad categories:
• Reversible or partially reversible dementias
o It is important to rule out treatable and potentially reversible
causes of dementia
o Find a reversible cause does not however guarantee that the
dementia will improve after the cause has been treated
o Causes include:
 Infections
 Toxins (alcohol, heavy metals, organic poisions)
 Trauma
 Glucose, liver metabolism etc
 Neoplasm, cancers
 Autoimmune disorders (ie/ LUPUS, MS)
 Nutritional disorders (ie/ look at proteins)
 Depression – (also known as pseudodementia) may
coexist with dementia (more than 1/3 of outpatients
and greater # in nursing homes)
• Nonreversible dementias
o Causes:
 Degenerative diseases
 Alzheimer’s Disease
• Cannot diagnose until autopsy
 Lewy bodies
 Parkinson’s Disease
• May or may not have a dementia
 Pick’s disease
• Characteristic findings in the brain
 Huntington’s Disease
 Vascular dementias – causes lying in vessels
 Multi-infarct dementia
• fine, abrupt decrease, plateau, then abrupt
decrease and plateau etc
 Cerebral embolism
• clot or something letting loose into the brain
 Anoxia
• lack of oxygen
 Trauma dementias
 Brain injury
 Concussions
 Sports injury
 Infections
 HIV dementia
 Opportunistic infections that affect the brain
 Creutzfeldt-Jakob disease (mad cow)
 Encephalitis

← DIAGNOSTIC EVALUATION

← The goal of this is NOT to make a diagnosis of dementia but rather try
fixing it.

← Ensure:
• A careful history and physical exam, including past history and the
older medical records
• Diseases and disorders associated with dementia may also be
detected
• A family history of dementia only weakly supports a diagnosis of
primary (non-reversible) dementia and shouldn’t interrupt
evaluation
• Evaluate diet and living arrangements – do home visits
• Evaluate present medications and medical history
• Do an alcohol history
• The physical exam should put special emphasis on neurological
deficits
• Mental status exam to determine the severity and course of the
disease
• Lab tests (syphilis, HIV)
• Studies for specific conditions or diagnoses if they are suspected
• Other diagnostic tests

← PHARMACOLOGY & OLDER ADULTS

← Pharmacodynamics: what the drug does to the body
← Pharmacokinetics: what the body does to the drug

← TISSUE PERFUSION

← Organs richly perfused with blood receive more drug initially than
tissues with a relatively poor blood flow.
• ie/ liver, muscle, heart, kidneys, brain and adrenals; thus, they
receive more drug than poorly perfused fat or bone during initial
distribution

← Thereafter, a redistribution occurs with the drugs accumulating in
tissues for which they have affinity.
• ie/ thiopental for fat, and tetracycline antibiotics for bone and teeth
(because they bind to calclum)

← Any tissue that has an affinity for a particular drug can retain it in high
concentrations.

← PLASMA PROTEIN BINDING

← Plasma proteins are found in the blood – they help with various body
functions. They ensure that vessels maintain oncotic pressure (enough fluid
in vessels).

← When malnourished, carbohydrates, fats and THEN proteins are broken
down. Fluid is lost from the vessels due to the decrease in plasma proteins –
causes edema.

← Normally, plasma proteins do not leave the vascular system and drugs
bound to them are denied access to the tissues.

← Only drug molecules free in solution diffuse thru the capillary
endothelium and equilibrate between the plasma water and the interstitial
water.

← Unless the capacity of the plasma proteins to bind a drug is saturated,
the ratio of bound:free drugs remains constant.

← As the free level of a drug falls, due to metabolism and/or renal
excretion, more drug leaves the albumin to become free in the plasma
before diffusing out of the vascular system.

← WHEN SATURATED… 22 MARCH 2010

← Plasma contains a finite concentration of albumin. They can be reduced
due to disease, malnutrition and normal aging changes.

← If enough drug is given it is possible to occupy all the binding sites on
albumin, thereby saturating the plasma proteins.

← When this occurs the free level of drug in the plasma will increase
suddenly.

← Then the pharmacological activity of the drug increases as more
molecules diffuse into the tissues.

← Factors that may affect plasma protein:
• Disease (ie/ cirrhosis)
• Older patients may have lower plasma albumin
o Age adjusted laboratory normals
• Malnutrition

← Drugs can compete for the available plasma proteins (ie/ warfarin and
salycilate).

← BLOOD BRAIN BARRIER

← Plasma protein binding prevents a drug from leaving the blood vessels.

← Drug molecules that are not bound to plasma proteins can leave the
blood vessels and enter the interstitial water of all tissues – with one
exception – THE BRAIN.

← Ionized molecules are practically excluded from entering the brain.

← Nonionized molecules, not bound to plasma proteins, enter the brain
easily. Lipid solubility also affects this.

← PHARMACOKINETICS

← What the BODY does to the DRUG – the ways in which it is processed
in the body. There are four basic components:
• Absorption
o Ie/ enteric coating
• Distribution
• Metabolism (biotransformation) and
o What happens, and where?
• Excretion

← PHARMACODYNAMICS

← What the DRUG does to the BODY – how the drug affects the body.

← CHARACTERISTICS OF OLDER PERSONS RELATIVE TO DRUG
DISPOSITION AND RESPONSES

← Older adults go through various changes:
• Reduced renal function
o Decreased blood flow (CO),
o Decreased GFR (ability to clean blood)
• Reduced serum albumin (plasma proteins)
• Relative increase in body fat
o Ratio of fat increases over water
• Reduction in lean body mass and total body water
o ICF down 10%
o Composition in general, changes
• Reduction in liver metabolizing capacity
o Ability of liver to break drug down
• Decreased cardiac reserve
• Decreased baroreceptor sensitivity
• Concurrent illnesses
• Multiple drugs
• Large inter-individual variation
• Sensitivity to drug(s)
NORMAL AGING PUTS ELDERS AT RISK OF TOXCICITY
BECAUSE:
-many organs have altered sensitivity to medication
-bladder
-eye
-brain
-drug treatment of one disease can worsen another causing a ripple
effect
-the risk of drug interactions increases with every drug added to the
regime
-many drugs can cause orthostatic hypertension – dizziness and risk of
falling

ASIDE: Chemical Intervention in Aging (2007), 2(4) 715-718. “Not


geropharmacotherapy 101” NOT TESTED ON

SEVERAL CONSIDERATIONS ARE IMPORTANT IN


DETERMINING THE EFFECTS OF AGE ON RENAL FUNCTION
AND DRUG ELIMINATION

← -There is a wide interindividual variation in the rate of decline of renal
function with increasing age (applying average declines to individual older
patients could result in over or underdosing).
← -Creatinine is a product of muscle metabolism. It can be measured
with a urine specimen, blood, or creatinine clearance (24 hour urine
collection, or Cockroft-Gault formula). Muscle mass declines with age,
therefore, daily endogenous creatinine production (in the body) declines (as
a result, a serum test may be ‘normal’ when renal function is reduced). The
point is that serum creatinine does not reflect renal function as accurately in
older adults as it does in younger adults (serum creatinine level does not
accurately reflect GFR in older adults).

← Many factors (ie/ state of hydration, cardiac output, and renal disease)
can affect renal clearance of drugs and are often at least as important as
age-related changes.

← A formula to estimate renal function in relation to age:

← CC (mL/min) = [(140 – AGE) (BODY WEIGHT KG)] / [(72) ( SC
mg/dL)]
← *useful when only data on serum creatinine (SC) are available, also in
initial estimations of CC for the purpose of drug dosing in older adults.

← When using drugs with narrow therapeutic-toxic rations, actual
measurement of CC and drug blood levels (when available) should be used.

← Ideally dose adjustments should be based on
← CC, which does not absolutely require 24 hour urine collection but can
be estimated on a timed urine collection of 8 hour duration.

← DRUG THERAPY IN OLDER ADULTS

← Do NOT rely on BUN levels as an indicator of renal function in the older
person. BUN is affected by muscle mass, level of hydration and dietary
intake of protein. Calculating the creatinine clearance provides a more
accurate assessment of how the drug will be metabolized and cleared by the
kidneys.

← If a patient is receiving two or more drugs that are highly protein
bound, the nurse should observe for drug interactions and variations in
responses to each drug.

← The rule of thumb for drug prescription in the older person is “start
low; go slow”. In other words, the drug should be administered at about one
half the recommended adult dose, and the health care provider should wait
twice as long as recommended in the literature before increasing the dose.
This rule will help prevent toxic side effects and adverse drug reactions.

← PRESCRIPTION DRUG USE & SENIORS

← EPIDEMIOLOGY OF DRUG USE:
• The general population versus the older population
o 66% of people will fill a prescription, 89% of older adults will
fill at least one
• Income
o Use of prescription drugs are higher in lower income groups
• Gender differences
o Females use more prescription drugs than men

← Drug expenditures are responsible for an increasing proportion of
health costs.

← Older adults are at greater risk of adverse drug-related events.

← THE APPROPRIATENESS OF PRESCRIPTION DRUG USE

← Judged in relationship to 4 CRITERIA:
• The match between need and treatment
o Overuse of drugs is not uncommon
o Common overused drugs include antibiotics, NSAIDs,
sedatives/hypnotics
o Some drugs were underused (beta blockers, inhalers)
o Underuse is more common in older adults vs general
population
• Appropriateness of therapy selection
o Prescribing errors account for an estimated 5-23% of drug-
related hospital admissions
• Seniors are more likely to receive potentially inappropriate
medication than middle-aged adults
• Cost-effectiveness of therapy selection
• Compliance (should be adherence)
o For many patients compliance with prescribed therapy is far
from ideal
o 11.4% of admissions to hospital have been attributed to
compliance problems

← There is evidence that the potential effects of drug treatment are
compromised by:
• The under and over-use of prescribed medication for certain
conditions
• Errors in the drug, dose and duration of therapy prescribed
• Suboptimal compliance

← Drug related illness is now claimed to be the 6th leading cause of
mortality in the USA.

← Adverse drug related events have been shown to be more common in
seniors:
• Primarily because they are more likely to be using a greater number
of medications, and
• Possibly because they are more likely to receive potentially
inappropriate medication

← NON-MEDICAL FACTORS INFLUENCING DRUG USE AND
OUTCOMES OF DRUG THERAPY

← The drug industry

← Health care system policy
• Physician density – the number of physicians prescribing for a
patient has been identified as one of the most important
determinants of drug utilizations and inappropriate prescribing

← Physician reimbursement policy is an important factor in shaping
practice patterns

← Physician characteristics
• Age and sex
o Older physicians more likely to prescribe:
 Heavily
 High cost drugs (new)
 Psychotropic drugs (particularly for women)
 Inappropriate prescriptions
 Poorer knowledge of drugs in older adults
 More likely to use drug sales people as sources of
information
o Male physicians are more likely to prescribe drugs
• Professional attitudes
o Task based physicians are more likely to prescribe drugs
• Practice characteristics
o If they have a high volume practice, or if they see patients
often – more likely to prescribe
o Physicians with nursing home practices and teaching hospitals
are less likely to prescribe inappropriate meds
• Training
o Lower scores on physician exams – more likely to prescribe
more
 Also, more likely to prescribe based on a symptom
(underdiagnosing)
 Prescribe meds that are contraindicated with older
adults (ie/ Demerol)
• Patient characteristics
o Gender
o Expectations
o Communication
o Time
o Compliance/adherence issues
 The number of drugs taken by a patient and the
complexity of the drug regiment is inversely related to
compliance
 Other factors:
 Social isolation
 Patient’s belief systems about health and drugs
 Patient’s interaction with physician
 Patient’s understanding of the treatment regimen
 Poor labeling instructions
 Complexity of the dosing regiment
 Safety packaging
 Demands that the dosing regimen makes on the
patient’s lifestyle
 Drugs to treat asymptomatic illnesses (ie/
hypertension)
• The drug
o Absence of evidence of the effects of prescription drugs on
older persons
o Seniors are excluded or disproportionately under-represented
in the evaluation of the safety, efficacy and effectiveness of
new drugs

← BLOOD PRESSURE & THE OLDER ADULT
← TYPES OF HYPERTENSION:
• PRIMARY (ESSENTIAL/IDIOPATHIC) HYPERTENSION
o Multifactorial and many causes
• SECONDARY HYPERTENSION
o Usually an identifiable cause
o Causes include:
 Renal disorders
 Renal parenchymal disease (tissue disease)
 Renal artery stenosis (narrow vessel)
 Rennin-producing tumours
 Endocrine disorders
 Acromegaly (big features)
 Hypothyroidism
 Hyperthyroidism
 Adrenal disorders (adrenal glands)
 Neurologic disorders
 Increased intracranial pressure (systolic/diastolic
move apart, bounding pulse)
 Sleep apnea
 Autonomic dysreflexia
 Medications
 Tyramine-containing foods
 Aged-cheese (cheddar)
 Chicken liver
 Yeast extract
 Beer, wine
 Acute stress
 Psychogenic hyperventilation
 Hypoglycemia
 Burns
 Alcohol withdrawal
 Vascular disorders
 Pregnancy-induced hypertension
• “WHITE COAT” HYPERTENSION
o People who are normally fine, but when coming to health care
providers blood pressure goes up (anxiety)
• ISOLATED SYSTOLIC HYPERTENSION (ISH)
o This is when just the systolic pressure is high (140 or higher,
but bottom number remains less than 90)
o Common in older adults
o Possible causes:
 Increased CO
 Atherosclerosis-induced changes in blood vessel
compliance or,
 BOTH
o Likelihood of developing increases with advancing age, as
does its severity
• MALIGNANT HYPERTENSION
o Severe hypertension (ie/ diastolic of over 110)

← EXOGENOUS FACTORS THAT INDUCE/AGGRAVATE
HYPERTENSION

← Prescription drugs:
• NSAIDs
• Corticosteroids and anabolic steroids
• Oral contraceptive and sex hormones
• Vasoconstricting/sympathomimetic decongestants
• Erthyropoeietin and analogues
• MAOIs

← Other substances:
• Licorice root
• Stimulants, including cocaine
• Salt
• Excessive alcohol use
• Sleep apnea

← HYPERTENSION IS DEFINED as a blood pressure greater than, or
equal to 140/90 mmHg, or a BP that requires treatment with an
antihypertensive medication.

← RISK FACTORS FOR HYPERTENSION

← Obesity
← Dietary habits (ie/ high sodium intake)
← Lifestyle habits (ie/ cigarette smoking, physical inactivity)

← Older adults and African Americans may have a heightened salt
sensitivity; thus, they may be more likely than other groups to develop
hypertension in response to sodium intake.

← CRITERIA FOR NORMAL BP & STAGES OF HYPERTENSION

ADULT BP SYSTOLIC DIASTOLIC

NORMAL < 120 < 80

PREHYPERTENSION 120-139 80-89

STAGE 1 140-159 90-99

STAGE 2 > 160 > 100


AGE-RELATED CHANGES THAT ALTER BAROREFLEX MECHANISMS:

Arterial stiffening
Reduced cardiovascular responsiveness to adrenergic stimulation

These changes cause a blunting of the compensatory response to both


hypertensive and hypotensive stimuli in older adults, so that the heart rate
doesn’t increase or decrease as efficiently as in younger adults.

Researchers are studying effects of obesity, hypertension and cardiovascular


disease as factors that alter baroreflex mechanisms in older adults.

Age-related chances that affect autonomic regulation of BP predispose older


adults to:
• orthostatic HYPOtension
o also known as postural hypotension
o a reduction in systolic BP and diastolic BP of at least 20
mmHg or 10 mmHg, respectively, that occurs within 1 to 3
minutes of standing, after being recumbent for at least 5
minutes
• postprandial HYPOtension
o a BP reduction of 20 mmHg within 75 minutes of eating a
meal (particularly breakfast)

← RISK FACTORS FOR HYPOTENSION

← ORTHOSTATIC HYPOTENSION:
• Pathologic processes
o Hypertension, including ISH
• Parkinson’s disease
• Cerebral infarct
• Diabetes
• Anemia
• Peripheral neuropathy
• Arrhythmias
• Volume depletion (ie/ dehydration)
• Electrolyte imbalances (ie/ hyponatremia, hypokalemia)
• Medications
o Antihypertensives
o Anticholinergics
o Phenothiazines
o Antidepressants
o Levodopa
o Vasodilators
o Diuretics
o Alcohol

← Symptoms:
• Weakness
• Headaches
• Dizziness
• Faintness
• Vertigo
• Lightheadedness
• Blurred vision
• Cognitive impairment
• Abnormal sweating
• Urinary incontinence

← Serious negative functional consequences, for example:
• Difficulty walking and maintaining balance
• Increase risk for falls and fractures
• Increased risk for:
o Strokes
o Coronary events
o Transient ischemic attacks

← ASSESSMENT:
• Initial reading after has been sitting or lying for at least 5 minutes
• Second reading after has been standing for 1 to 3 minutes


← POSTPRANDIAL HYPOTENSION
• Pathologic processes
o Systolic hypertension
o Diabetes
o Parkinson’s
o Multisystem atrophy
o Medications
 Diuretics
 Antihypertensives ingested before meals

← Physiologic changes that likely cause postprandial hypotension include:
• Impaired baroreflex mechanisms
• Quicker rate of gastric emptying
• Release of vasoactive GI hormones
• Impaired autonomic regulation of GI perfusion

← It’s likely that postprandial hypotension is due to the combined effects
of:
• Age related changes (especially in autonomic CV control), AND
• Additional adverse effects of concomitant pathologic processes

Postprandial hypotension is associated with the consumption of


carbohydrates (particularly glucose).

It’s more likely to occur after a consumption of warmer foods that are high
in carbohydrate content.

It contributes to:
• Falls
• Syncope (fainting)
• Hip fractures
• Myocardial infarction
• Stroke-related dizziness
• Frailty
• Malnutrition

← Recommendation: any older adult who falls, has syncope, or loses
consciousness should be evaluated for postprandial hypotension.

← ASSESSMENT:
• Initial reading before a meal
• Second and third readings at 15 minute intervals after the meal in
completed

← NORMAL FINDINGS

← A normal BP is less than 120 mmHg systolic BP, and less than 80
mmHg diastolic BP.

← The normal difference between lying/sitting and standing systolic BP is
20mmHg or less after standing for one minute.

← The normal difference between lying/sitting and standing systolic BP is
10mmHg or less after standing for one minute.

← THINGS TO REMEMBER WHEN TAKING BP IN OLDER ADULTS

← There may be an increase in variability of BP.

← Post prandial drop in BP may occur.

← An uncomfortably full bladder will increase BP.

← Many diseases and therapies can influence BP and cause postural
hypotension.

← Auscultatory gaps may be more common.

← Consistent differences in BP between arms may be more common in
older persons

← The incidence of arrhythmias increases with age.

← Pseudohypertension occurs predominantly in older persons.

← Self-measurement of BP may be difficult.

← TARGET ORGANS (OR END ORGANS):

← Those body organs (ie/ brain, eyes, kidneys) that are likely to be
damaged by untreated hypertension.

← HYPERTENSIVE TARGET ORGAN DAMAGE:
• Fundoscopic exam
• Left ventricular hypertrophy
• Hypercreatinemia
• CAD, PVD
• Abdominal aortic aneurism

← Examples of target organ damage:
• Cerebrovascular disease
o Transient ischemic attacks
o Ischemic or hemorrhagic stroke
o Vascular dementia
• Hypertensive retinopathy
• Left ventricular dysfunction (bigger)
• CAD
o MI
o Angina pectoris
o CHF
• Chronic kidney disease
o Hypertensive nephropathy (GFR <60 mL/min/1.73m^2)
o Albuminuria
• Peripheral artery disease
o Intermittent claudification
o Stroke (including transient ischemic attacks and/or vascular
dementia)

← NOTE: The absolute risk for all types of CV morbidity and mortality is
higher among persons with target-organ damage than among those without.

← ASSESSMENT FOR HYPERTENSION

← LAB TESTS:
• Hct, urinalysis for protein, blood and glucose; creatinine and/or
BUN; electrolytes; ECG; chest xray

← Assess BP in lying, sitting and standing positions (in that order).
Positional drops of less than 20 mmHg are normal.

← Assess physical and mental function at various BP levels.

← Use the two-step palpatory-ausculatory system as you have been
taught.

← Right size cuff.

← Fundoscopic exam (for arteriovenous nicking and toruousity,
hemorrhages and papilledema)

← Height and weight

← Examine neck vessels for bruits and distention.

← Inspect thyroid size.

← Auscultate lungs for pulmonary failure (chest xray as well)

← Evaluate heart size (left ventr), rate, precordial heave, murmurs,
gallops, arrhythmias.

← Inspect abdomen for aortic size, aneurysm, abdominal bruit and
kidney size.
← Aging is a holistic (all aspects), natural and expected process that
occurs from conception, until death. The rate, type, and degree of holistic
changes experienced during the lifespan are highly individualized

← Holistic changes are affected by:
• Determinants of health
o Genetic factors
o Diet
o Health
o Stress
o Lifestyle
o Knowledge
o Gender expectations

← Therefore, we can see that aging is multifactorial and very complex.

← There are individual variations in aging among older adults, and there
are differences in the pattern of aging of various body systems within the
same person – with some similarities as well.

← GENERAL CHANGES
← - The body has fewer functional cells, overall
← - Lean body mass decreases
• fat tissue increases (until 6th decade of life)
← - ICF decreases
• 10% decrease in older people
• leads to dehydration
← - Grey hair and wrinkles
← - Body contours gain a bony appearance (due to lower muscle mass)
along with deepening of hollows (axilla, supraclavical, prominent ribs, orbits)
← - Loss of tissue elasticity
• Collagen proteins change
← - Loss of subcutaneous fat content (causing elderly to feel cold)
• Tissue and skin move against each other and cause shears (position
extremely important)
← - Stature decreases
• immobility causes calcium to leave
• very susceptible to UTIs, pneumonia, blood clots etc

← CHANGES IN HEART AND BLOOD VESSELS
← - Heart size doesn’t significantly change with age
• if it does, there is a problem
o valve problems
o narrow aorta
o athlerosclerosis
← - Valves become thicker and more rigid (still working though)
• left sided heart failure – pulmonary edema (backflow of blood)
• right sided heart failure – CHF
← - Reduction in CO (HR x SV) under physiological stress
← - Lower SV
← - No change in resting rate
← - Lower sensitivity of blood pressure regulating baroreceptors
← - Vessels in the head, neck and extremities become more prominent
(due to thin subcutaneous layer)

← CHANGES IN THE LUNGS
← *Remember: Ventilation  Diffusion  Transportation
← - The rib cage becomes more rigid
• the anterior-posterior diameter increases (often demonstrated by
kyphosis)
← - Thoracic inspiration/expiration muscles are weaker
• thus, increased residual air in lungs
← - Lungs become smaller and more rigid – less recoil
← - Risk of aspiration is increased due to the blunting of cough/laryngeal
prominences
← - Decreased ciliary action
← - These changes cause lung expansion, insufficient basilar inflation and
decreased ability to expel foreign/accumulated matter.

← *Note: In older adults, the fact that they have lower O2 effects the fact
that they take another breath. Unlike the typical causes which is CO2.

← CHANGES IN THE GI SYSTEM
← - Healthy gums indicate an overall, healthy body (due to many blood
vessels etc)
← - Should not lose teeth with age
← - Less acute taste
• Sweet suffers, vs sour and salty
• Older people more prone to Type 2 Diabetes
← - Saliva level is down 1/3 (chew well!)
← - Thirst sensation can be blunted, and since ICF already down 10%
can easily dehydrate
← - ADH changes in elderly people can also cause more dilute urine

← ESOPHAGUS
← - Decreased motility
← - Slightly dilated
← - Longer time to empty
← - Potential for aspiration
← - Weaker cough muscles
← - Relaxation of esophageal/cardiac sphincter
← - Reduced gag reflex

← *Note: Older individuals should not lie down directly after eating (up to
an hour after) – and 5-6 smaller meals a day is better than 3 large ones!
Chewing, less distractions (conversations, phone calls etc).

← STOMACH
← - Reduced motility/action
← - Reduction in hunger contractions
← - Less acid in stomach (higher pH)
← - Less pepsin (protein breakdown)
← - Cardiac sphincter may be looser

← INTESTINES
← - Atrophy (small)
← - Fewer cells on the absorption size
• absorption challenges with iron, calcium, Vitamin B, B12 and D
← - Normal aging shouldn’t cause constipation
• Reduced foods, lack of fluids
• Less bulk in diet
• Reduced awareness of need to defecate

← *Note: Laxatives are NOT harmless.

← LIVER
← - Smaller in size
← - Function is the same and tested with the Liver Function Test
← - Drugs take longer to metabolize

← URINARY SYSTEM
← - Decrease in renal mass
← - Reduction in the number of nephrons
← - Reduction in renal blood flow
← - Reduction in GFR (10% down per decade after 40)
← - Creatinine, a product of muscle metabolism is measured in 3 ways:
• urinalysis
• blood serum (if high, indicated kidney problems)
• creatinine clearance (collecting urine for 24 hours)

← CREATININE CLEARANCE = (140 – AGE) x LEAN WEIGHT [KG] / 72 x
C.C.
← (if women, multiply by 0.85)

← - In older adults, give lowest possible medication doses
← - Serum monitored closely

← *(140 – AGE) x (LEAN WEIGHT (KG) / 72 x SC (to estimate for an
older adult)

← BLADDER
← - UTIs very common in older adults
← - Frequent urination (less elasticity)
← - Urgency, nocturia
← - Complete emptying ability is not good

← *Note: Keep in mind to discover what an older persons normal
temperature is. Since metabolic rate decreases with age, a normal
temp will not necessarily be 37.

← - Micturition reflex (signal delay)
← - Incontinence is NOT normal
• tumours
• diabetes
• drug induced

← - Stress incontinence:
← - Urgency incontinence:
← - Overflow incontinence:
← - Reflex incontinence:
← - Functional incontinence:

WEEK TWO NOTE BEGINS
CHANGES IN THE REPRODUCTIVE/SEXUAL SYSTEMS
- Males have lower sperm count, but do not lose ability to engage. ¾ males
over 65 have benign prostate (enlarged) but may be harmful as well – but
even if it isn’t it can cause physical damage (problems in excretion ie/
frequency (crimped ureter) – good to have it ruled out

-PSA is not always reliable

- Women may lose subcutaneous fat, hair and a flatter labia (due to less
tissue). Uterus shrinks (but if on hormone replacement therapy the
endometrial lining may still respond – but needs to be ruled out as bleeding
may be other things). Vaginal canal is more alkaline (pH higher) – bacteria
likes these environments so older women more at risk for infections.
Decreased secretions (use water-soluble lubricant). Women, also do not lose
ability to engage/enjoy.
Sexual dysfunctions are often a symptom of something more serious.
Many sexual problems were identified as possible red flags of underlying or
imminent medical conditions.

Sexual dysfunction may mean:


• heart failure
• diabetes (inside the vessels you could get ascloferosis- which could
narrow the lumen or the opening of the vessel, which will effect the
amount of blood delivered)
• depression(life events, other diseases, drugs, alcohol-look to see
what depression is due to)
• Parkinson’s
• MS (neurological-neural sheath(coating) becomes interrupted so
the impulses cannot be transmitted)

← Men with erectile dysfunction (it is not normal), the most common
sexual disorder in older men, are often at increased risk of heart disease.
(they might be feeling okay-but are not okay. Then they take VIAGARA- if
the man had heart and vessel disease, and your shunting blood to a certain
area, you are robbing blood from another area[ex. The eye, causes
blindness]-these quick fix things are not without consequences).
Hyperdemial ? HDL is the bad cholesterol. Injury from trama or iradiation

← A woman’s lack of sexual desire could be related to:
• Depression(need to know baseline- if there is a change we need to
look into that)
• Hormone conditions
• Kidney failure
• Diabetes
• Other chronic diseases (arthiritus)
• Hypertension
• High Cholesterol
• Smoking
• Pelvic injury or surgery
• Adverse drug reactions
• Decreased estrogen

← In addition, ask
• Who they have sex with
• How frequently
• If they engage in potentially risky behavior (not using safe sex,
multiple partners, sharing toys, not bathing before and after)

← Another risk is infectious disease. The prospect of better sex may
persuade people to lead healthier lives.
← MEN:
Prostatitis- inflammation of the prostate
Certain prostatectomies
Arterial Schlerosis (schlerosis-less elasticity in the arterials)
Cord compressions (arthiritis)
Heart disease
Respiratory disease- COPD
Arthiritis
Diabetis
Stroke
Alcoholism
Sleep Habits

WOMEN:
Cystocile- cyst on the bladder
Heart disease
Respiratory disease- COPD
Arthiritis
Diabetis
Stroke
Alcoholism
Sleep Habits

← It is NOT normal to lose sexual abilities/desire with age.



← CHANGES IN THE MUSCULOSKELETAL SYSTEM
← Muscle mass is typically reduced – but may be brought back with
weight therapy (light weight exercises). Muscle strength may be decreased
(increased with Tai Chi, running etc). Muscle movements may be decreased
a bit. Tendons (muscle to bone) may shrink a bit, and harder(decreased
reflexes in arms in a neurologic exam- should be bilateral or there is more
likely a problem, reflexes may be totally lost in the abdomen, but should be
maintained in the knee muscle tremors might be normal: pay particular
attention to these- rule out causes of tremors [may be due to disease]
before assuming they are normal). Bone mineral mass may be reduced (also
due to other things NOT normal to aging) – brittle bones. Calcium intake
from natural foods is extremely important – natural foods first, supplements
second. Nutritional requirements are different for that of older adult – ie/
more calcium for older adult [begin to lose calcium after 35, especially if
immobile, hold calcium if active, lose it if lazy]) vs younger! May also have
reduced height (can lose up to 2 inches-men are sometimes overlooked for
osteoporosis). Risk for kyphosis – hump back, flexion in elbows, knees etc.
When it comes to gait, men may walk with a wider one, women with a
narrower one. Decreased reflexes in arms, abdomen may be totally absent.
May have tremors – benign, or things like Parkinson’s (resting tremor).

← Risk Factors For Primary Osteoporosis (weakening/loss of calcium
in bones) ***don’t worry about the diseases stuff so much, more the causes
ex. age!
• Age
• Females
• Amenorrhea (premature menopause [hysterectomy], oophotectomy
[removal of ovaries], secondary amenorrhea, mensis- away from
menstruation)
• Family history
• Race (Oriental or Caucasian)
• Low lifelong calcium intake (including lactose intolerance)
• Thin body habits (not a lot of pressure on bones in general)
• Sedentary life-style or immobilization
• Smoking
• Alcoholism
• Protein-calorie malnutrition
• Gasrectomy (part of stomach removed)
• Bulimia/anorexia
• Chronic obstructive lung disease
• Sacroidosis
• Malabsorption syndrome

← Causes of secondary osteoporosis include: ****EXAMPLES NOT ON
EXAM***
• Endocrinopathies (pathology of endocrine glands)
o Hypercortisolism*** Examples ***
o Hyperthyroidism
o Hyperparathyroidism
o Hypogonadism
o Hyperprolactinemia
• Drugs- don’t need to know specific meds, just that medications
could contribute to osteo
o Corticosteroids
o L-thyroxine
o Alcohol
o Aluminum containing antacids
o Barbiturates
o Phenytoin
o Heparin
o Methotrexate
o Tobacco
o Isoniazid
• Other conditions
o Immobilization
o Rheumatoid arthritis
o Diabetes mellitus
o Osteomalacia
o Chronic renal failure
o Hepatic disease
o Scurvy
• Tamblyn- doctor who researched benzodiazepines and found that
over 20 million dollars in debt due to improper prescription of the
medication causing things such as falls

← CHANGES IN THE NERVOUS SYSTEM
← The weight of the brain may decrease, as well as blood flow – but
should not effect functioning. Confusion is NOT normal, at ANY AGE – it is
disease, drugs, etc. Nerve conduction can be slower; slower reflexes, and
slower response to many stimuli (ex. Test bath water before getting in,
because it will take them longer to get out, resulting in a burn).Slower
response to changes in balance.

← Sleep/Wake:
• Related to hypothalamus (controls; appetite, sleep/wake, thirst
regulation, etc.)
• Need to monitor with head injury since brain cannot expand in the
cranium (no space) – so will put pressure on hypothalamus (causes
sleep) and will die since brain will continue to expand. Hypertonic
IV solution will take out fluid.
• Stages Of Sleep:
o 1 – Beginning, light sleep, NREM
o 2
o 3
o 4-psysiological restoration
o 3
o 2
o REM (short)- little bit of dream
o 2
o 3
o 4
o 3
o 2
o REM (a little longer)
o Cycle repeats.(every time your REM gets a little longer- cycle
repeats 7/8 times)
• Older persons may have less time in stage 4 (deep sleep), and will
have uniform times in REM (vs. getting longer each subsequent
time).
• ASK if they get up in the night, if so ask why. Maybe its nocturia-
they may be diabetic.May say they can’t breathe- may have heart
failure on one side.
• Hypothalumus

Sensory Organs
• Eyes/Vision
o Presbyopia (normal aging [begins around 40] –
farsightedness due to less elasticity of the eye lens). May not
occur as quickly in people who are generally nearsighted.
o vision field narrows (regular vision checks – can be caused
from glaucoma – starts from outside, is high pressure in the
eye, can be treated with eye drops or surgery) – risk for
developing glaucoma is increased
o Age related macular degeneration (AMD – losing centre vision
first)
o Pupil is less responsive to light (may need more light)
o Lens becomes stiffer/more opaque – cataracts
 More prevalent in individuals near the equator
o Yellowing of the lens- may have trouble differentiating
between blues, greens and purples[DO NOT USE THESE
COLOURS FOR PRESENTATIONS!]
o Vision depth can become distorted
o Dark and light adaptation takes longer (risk for falls-
encourage leaving a light on inside the house, and sensor
lghts outside house)
o Reduced lacrimal secretions (dryer eyes)
o Blinking reflex may become slower
o Arcus senilis – a narrow, opaque band surrounding the iris
(older age)
o Corneal sensitivity is diminished (protective reflex of the eye
may be slower- wear protective eye wear when gardening,
mowing the lawn, etc.)
o Visual acuity decreases with age(sharpness of vision)***don’t
say this for a normal aging change of the eyes-be more
specific
o Age macular degeneration, first lose central vision
o
-macula
-dry involves the cells, wet involves the vesicles

• Ears
o Presbycusis (gradually loss of hearing with age) – due to
changes in the inner ear
 Can also be affected by other things such as noise,
vibration
 First lose the high pitched soft sounds (s,f,ph,th)
 Speech could sounds distorted to them
 Many factors contribute to presbycusis (such as
continues exposure to loud noise)
o Thicker hairs in ear canal with aging can affect hearing
o Wax also thickens with age (cerumen) due to increased
amounts of keratin
o Equilibrium/balance affected with aging – slower reflexes etc
• Smell
o About ½ older people lose some ability of their smell
• Taste
o 1/3 less saliva
o can be reduced – overseasoning (salt, sugar etc)
• Touch/Sensation
o May be reduced
o Change positions frequently – delays in feeling pain etc.
o Watch hot water (>43 C,), room temperature (24 C – never
lower [below 21 – hypothermia]) – elderly more susceptible
to cold temperatures (can lead to confusion, death)

← CHANGES IN THE IMMUNE SYSTEM
• Ability to fight infection/protect yourself becomes weaker in older
adults (health protection is important!)
o May exhibit atypical signs/symptoms of disease – actually
S&S given by the older adult will be vague/ atypical and
subtle
o Encourage getting flu vaccine, pneumovax vaccine etc.
o Encourage hand washing etc.

← THERMOREGULATION
• Normal body temperature may be lower – good to know baseline so
you can monitor based on their normal temperature.
• Reduced ability to respond to cold temperatures (due to reduced
sub-Q tissue, and decreased muscle mass)
• Differences in responses to heat
• Narrow window of safety – too high, too low = can get very sick
(core and environmental is important)
• May not be able to sweat as much when hot (decreased CO – lower
ability to shunt blood around etc)

← Principle for prescribing to older adults is to prescribe half the dose –
since it takes longer to excrete, wait twice as long to increase it, and monitor
very closely. Start slow, go slow.

← CHANGES IN THE INTEGUMENTARY SYSTEM
← SKIN
• Skin may become dryer, less elasticity
• Skin can be affected by multiple factors; smoking, sun exposure,
etc.
• Elderly people bathe less frequently
• Use of skin cream (to seal in moisture)
• Fragile – caution about damage to skin (shearing when immobile)
o Can wear socks inside out (prevents seams from rubbing
against/irritating skin)
o Encourage proper nail care (clipping etc – prevents fungal
infections)
o Cotton socks – allow feet to breathe better
• Subcutaneous fat is lost – elderly now more vulnerable to hot/cold
temperatures
o As lost, wrinkles result, sagging, lines (normal)
o Non-normal effects result from smoking
• Skin condition enhancement occurs by rehydration (1500 mL fluid a
day)
• The skin immune response declines
o More prone to skin and nailbed infections (nailcare is
important)
o Encourage handwashing, use of gloves in the garden etc
• Benign (harmless) neoplasms (tissue growth) as can malignant
ones
o Need to know normal vs abnormal changes in the skin
o Encourage regular skin checks
o Melanoma is on the increase-can be anywhere on the body

← HAIR
• Less colour in hair – may get white/grey
• Hair loss
o Some diseases cause this (hyper/othyroidism)
• Losing eyebrows/hair
o Hypothyroidism
• Thinning of the hair on the head, and in the axilla (armpits) and
pubic area as well
• Hair may grow a little slower than it used to
• Hair in nose and ears may become thicker (think: mechanical
obstruction – oxygen, hearing aid etc)
o Higher amount of keratin in the wax – gets stiffer with age
(blockage in the ear)
o Hearing tests are a good idea
• Growth of facial hair (in women)
o Can also be due to non-aging factors such as medications,
hormonal imbalances
• Increased growth of eyebrow hair, ear hair and nostril hair (in men)
o Think: if giving oxygen can be drying – make sure to be
checking and using appropriate system to ensure client’s
comfort (patency – ensure everything is OPEN)

← NAILS
• Iron deficiency – curved nail
• COPD – flattened nails (clubbed nails)
• Normal changes:
o Nails grow slower
o More fragile
o Little more brittle

← Infection control is extremely important with care of nails and skin
(preventing portal of entry for infection). Nutrition and hydration enhances
condition of skin. Avoid the shearing effect of immobility – and bathe a little
less frequent to prevent drying out of the skin.

← PERSPIRATION
• Older adults may not perspire as much as they used to – cannot
cool down as easy as younger adults
• Decreased number/function of sweat glands

CHANGES IN THE MIND-**causes of confusion can add to this note
in 2050
• Can be affected by a lot of abnormal things
o Health status, genetic factors, education, activity (level),
physical and social changes (meanings given), losses, sensory
impairments (normal or abnormal), feelings, self-attitude,
social isolation

PERSONALITY
• Should not change (drastically) with age
• If it does change – consider underlying events (ie/ medication,
retirement, depression [very prevalent in older adults], new
diagnosis, etc.)
• Self attitudes, issues people are dealing with, loss, health status
may affect personality – but with normal aging should not change
drastically
• If it does – time to investigate a little further
MEMORY
• Retrieval time may take a little longer (long term memory)
o Especially if not used routinely
• Benign(harmless) forgetfulness (normal)-

INTELLIGENCE
• In the past, most studies were done cross-sectionally (comparing
younger to older people – not fair)
• Now using longitudinal studies (following the same people over
time)
• Basic Intelligence:
o Structure of facts and knowledge
o Supposed to be maintained with normal aging
• Crystalized Intelligence
• Fluid Intelligence
o Problem solving, non-intellectual performance, creative
capacities, process of thinking
o Can decline with normal aging

LEARNING
• Myth: Can’t teach an old dog new tricks
• Because of this myth older adults are not taught as much as they
should be (ie/ medications)
• Unlearning/relearning may be difficult and take some time
• Speed may be slower (unraveling) but once unraveled can keep up
• Need more teaching resources – and shaping teaching regarding
communication, older adults etc

ATTENTION SPAN
• May be more distracted- may only last about 45 minutes (ie/ noise
in the hallway)
• In terms of presenting information – may wish to break things up
(have a break etc)
• Longer approach

← *Confusion is NOT normal.

← AGE RELATED CHANGES IN ACUTE CARE FACILITIES
• Hospitals are considered dangerous places for older adults
• With meds, give lowest possible dose – monitor accordingly and
increase minimally if needed
• Age adjusted lab tests

END OF WEEK TWO NOTE


Words & Language
← Give me knowledge so I may have kindness for all.

← Words & Their Power To Affect Self-Image & Development
← Words can destroy. What we call each other ultimately becomes what
we think of each other, and it matters.

← There are links between language and culture – language shapes
culture, and culture shapes language.

← Miscommunication may be the cause of the most problems.

← Words are powerful.

← The words we use have great power to affect:
• Your self-image
• The self-image of the other – and the relationships you establish
with others

← RNs who use words skillfully can exert great influence with just a few
of them.

← Harness the power that words have in order to affect your
relationships with your significant others and your relationships in practice
(ie/ with patients, other RNs, other colleagues, agencies, government etc).

← Words & Meaning
← Words are symbols that represent something else. They can represent
processes, health states, objects – anything. They are triggers and are laid
with meanings.

← Words are arbitrary.

← Words are context bound.

← Words are culturally bound.

← Words can have a denotative (content, objective) meaning and
connotative (feelings, subjective) meanings.

← Words communicate concrete or abstract meaning.

← Recognize The Power Of Words
← Words have the power to create.

← Words have the power to affect thoughts and actions. Language should
support diversity.

← Words have power to affect and reflect culture.

← AVOID WORD BARRIERS:
• A communication barrier is something that keeps meaning from
meeting
• Words can create major misunderstandings as well as deep
connections

← Specific Barriers To Understanding:
• Bypassing: one word, two thoughts
• Bafflegab: high-falutin’ use of words
• Lack of precision: uncertain meaning
o Malapropism – meanings are in people not in words (not
inherent in words); restricted code (secret language or
jargon)
• Allness: the language of generalization
• Static evaluation – language of rigidity
• Polarization – language of extremes
• Biased language – insensitivity toward others

← Using Words To Establish Supportive Relationships
• Debate versus dialogue (overhead)
o There is one right answer and I have it, versus many people
have pieces of the answer – together you can find the best
solution
o The goal is to win versus the goal is to seek common ground
and interest
o The focus is on combat; prove that you are right and the
other person is wrong versus the focus is on collaboration;
seek common understanding
o Search for weakness and errors in others’ positions versus
search for strengths and value in truth in what others say
o Defend your views versus using the contributions of others to
improve your thinking

← Be flexible rather than rigid toward others.

← Present yourself as equal rather than superior (elaborated code).

Using Words To Create A Supportive Climate

Avoid sexist language


• Benefits of non-sexist language:
o Non-sexist attitudes
o More other-orientated
o Speech is more contemporary and unambiguous
o Empowering/confirming of the other

← Language about sexual orientation

← Avoid ethnic or racially bias language

← Avoid language that demeans one’s age, ability or social class

← Describe your own feelings rather than evaluate the behaviour of
others

← Solve problems rather than control others

← Be genuine rather than manipulative
• Being congruent – what you think = what you say
• If not genuine become a pseudo-self

← Empathize rather than remain detached from others
• Put in others shoes, try to see how they are feeling
• Tentative
o Getting a sense of the situation, show client you are listening
o Am I correct that…
o Do I understand…
o Are you saying that…
• Thinking
o You’ve been diagnosed with…
• Feeling
o And your world is falling apart…
o The emotional aspect

← Be flexible, rather than rigid toward others.

← Present yourself as equal rather than superior (elaborated code).

← Principles For Considering The ‘OTHER’ When Communicating
With Him/Her

← Meanings are in people not in words.
← Think before you speak – words can hurt.
← Say what you mean and mean what you say.
← Speak to others as you wish to be spoken too.

← “We thought because we had power, we had wisdom.”

← “There are times in politics when you must be on the right side, and
lose.”


Socially Constructed Determinants of Health
← Age, race, gender, ability, location, water, religion.

← The Power of Language

← The terms EQUITY and EQUALITY
• EQUALITY refers to a certain extent to SAMENESS or
EQUIVALENCE, thereby obscuring, even erasing, people’s
differences, whereas
• EQUITY allows for individual differences while working toward a goal
of social justice for all

← Try to avoid presuming sameness and treating people equally
• Gender is about more than women (biological sex). It provides a
window for exploring how power inequities can affect women due to
differences in race, age, sexuality, ability, size, geographic location,
social class etc. It also provides a window for examining how power
inequities affect men.

← Gender: A Social Structural Variable
← Society ascribes a package of behaviours (gender roles) that are
considered ‘normal’ or ‘appropriate’ for our particular sex.

← Socialization of gender roles:
• Parents
• Peer groups
• Schools and texts
• Media

← Common gender-based stereotypes that are widely accepted in our
society:
• For men
• For women

← If integrated, such stereotypical expectations could influence many
aspects of our lives.

← Androgeny:
• Flexibility in gender role
• Integrated aspects of masculinity and femininity
• Characteristics of androgenous people

← Components of gender:
• Understanding gender in terms of three categories of determinants
allows you to examine separately the modifiability/changeability of
the determinant that may be causing a certain health outcome
• There are 3 components relative to nursing practice:
o Dividing the study of gender differences into:
 Biological
 Biological sex
 Focus: examining hormonal, genetic or
anatomical factors as potential causes of health
challenges
 Psychological
 Gendered selves
 Focus: differences in health practices, coping
skills, personality and self-concept and how they
may lead to differing health outcomes
 Social/Cultural
 Social base
 Focus: shared beliefs about what constitute
appropriate”; cultural, social, economic
environments characteristic for each sex

← OUR LIVES BEGIN TO END THE DAY WE BECOME SILENT ABOUT


THINGS THAT MATTER.

← Pioneering Policy
← Canadian nursing has had a long tradition of policy leadership.

← Nursing is increasingly finding its voice in shaping the policies and
practices that affect the health of people and, as well, their own health an
work.

← Nursing is now taking its rightful place in shaping the policies that
influence the health of the world’s populations.

← Characteristics of Policy Makers and Policy Situations Today
← The object of policy making may be diffuse, obscure and hard to
define.

← Policymaking is strongly adversarial and generative of conflict.

← Many levels of policymaking and the many vested interests and
pressure groups render making integrated or unified policy most difficult.

← Policymakers (PMs) have difficulty communicating with experts, whose
expertise may be narrow, specialized and highly disciplinary.

← PMs usually have backgrounds in areas that seek confirmation in rules
and procedures rather than seeking novelty and innovation.

← Policy Defined
← Prudence or WISDOM in the management of affairs.

← Management or procedure based primarily on material interest.

← A definite course or method of action selected from among alternatives
and IN LIGHT OF GIVEN CONDITIONS to guide and determine present and
future decisions.

← A high-level overall plan embracing the general goals and acceptable
procedures especially of a governmental body.

← Policymakers everywhere are doers of ideological work.

← Ideologies have agendas, aims, claims (to make us believe them)

← These are some examples:
• Montreal General Hospital (1970s)
o Consider complexities in people’s lives and known them as
people (equity)
o Everybody has knowledge
o Team
o Coordinated (conferences, walk arounds, discussion)
 Prevents duplication etc
o Consultation
o Complexity
o Power sharing
o Health
o Accountable to the patient – not to the organization
o Called by professional title
o Postformal thinking
• Managerialism (Today)
o Call them beds (equality)
o HCP knowledge
o Decrease cost
o Increase efficiency (get the 9 people out of cardiac and get
the 9 people from emerg in – faster the better)
o Time is of the essence
o Accountability to the organization, NOT the people
o Restructuring (ie/ staffing, hiring less qualified people)
o Simplicity
o Narrow models (ie/ medical model)
o Keep people moving, less time spent staying in hospital
o Rationalizing
o Not staff, professional – but workers
 Devalues professional input
o Formal operations thinking

← Frameworks for Policy Development
← Hierarchial bureaucracies:
• Concentrenic power and policy decisions at the top
• Works when we believe there is no more money
← Staged-rational approach:
• Use specialized groups of experts (in chimneys or silos) who have
their own ways of viewing and approaching issues, their own
criteria of evidence, and their own bodies of knowledge. As well,
they often have different and conflicting demands. Under these
conditions ministers are forced to shared power with specialist
advisors.
← Policy making in complex environments:
• Strive to recognize complexities in the current policy scene and try
to take policy development in new directions

← Formal health care has a history, a perspective, an objective and a
political agenda, all of which are rarely made known to patients or even to
care providers.

← Contexts for formal health care are part of the health care system.
Thus, they often reflect power structures of the larger social institution of
health care and of society itself.

← Many issues arise when healthcare practices are examined without
considering the sociohistorical context along with the local realities/lived
experiences of patient and of care providers.

← Within social institutions like health are there are often shifting,
sometimes contradictory and always complex relations of power between
and amongst stakeholders, based on axes/dimensions of difference like race,
gender, sexuality, size, age, ability, access to material possessions, class,
affiliations, diseases, geographic location etc.

← THUS, health care is always a political endeavour.

← It has a PERSPECTIVE:
• It is rooted (consciously or otherwise) in a historical context, a
certain frame of reference, and a discourse, including values about
WHO and WHAT are important.

← The tension between that which we choose to view as important and
that which we choose to view as less important is what some call POLITICAL,
because it has CONSEQUENCES. There are winners and losers.

← Question/contest/trouble/disrupt the TAKEN FOR GRANTED (the
presumed) in your practice, in your lives and in society.
• For example, unarticulated assumptions about race, age, gender,
models used for care, that there is not enough money in health
care.

Social Location In Society

Social location is, by definition…. RELATIONAL.


• It depends on the ‘other’ against who we measure ourselves (us
versus them = a binary relation)

← We think we can tell a person’s ethnicity (from name, skin colour,
dress), gender (often we ignore transgendered and transsexual), age,
language(s), academic ability, possible successes or failures, etc FROM THE
VERY FIRST GLANCE.


Health & Policies
← All ideologies are political – and have consequences.

← Policy making is ideological – people will try to shape it their own ways
(that fit their own agendas). They can constrain people, or can
facilitate/support people.

← Leadership is ideological work. It can be professional (ie/ RN), formal
(ie/ an appointed position), informal (ie/ because of who you are). Leaders
can lead in different ways as well:
• Hierarchical
o Top-down
o Devalues and disempowers people
• Shared power
o Values and empowers people

← Managerialism is a dominant value in health care and society:
• Accountability
• Efficiency
• Cost, money and budget
• Rationalizing things
• Restructuring

← Leading health indicators:
• Physical activity
• Overweight and obesity
• Tobacco use
• Substance abuse
• Responsible sexual behaviour
• Mental health
• Injury and violence
• Environmental quality
• Immunization
• Access to health care

← The Ottawa Charter:
• Prerequisites to health (conditions for health):
o Peace
o Shelter
o Education
o Food
o Income
o Stable eco-system
o Sustainable resources
o Social justie
o Equity
• Health promotion actions means:
o Build healthy public policy
o Create supportive environments
o Strengthen community action
o Develop personal skills
o Reorient health services (develop a health care system that
contributes to health, generates health)

← Genuine Progress Index Atlantic (NS GPI)
• Is not affiliated with any political party or interest group
• “What we measure is literally a sign of what we value as a society)
• The GPI is an alternative to the practice of equating progress with
economic growth alone
• Is intended to be a pilot project for other provinces in Canada and
to serve in a springboard for other applications at all levels,
including globally
• The GPI consist of 22 social, economic and environmental
components under these headings:
o Time use
o Natural capital
o Environmental quality
o Socioeconomic
o Social capital

← Recidivism – readmission
• Needs were not met the first time

← Regulated Health Professions Act:
• RNs
• Physicians
• Dentists
• Pharmacists, etc

Canadian College Of Health Services Accreditation (important!)

← Lots of policy changes concerning automobiles, cell phones and make-


up during driving on the radio.

← Gender bias in older adults: women receive less acute care than men.
There is hard evidence to support this. It could also be that the older
women don’t present as clearly as men…

← CTV website: man who was tazered in the Vancouver airport.

← When we understand behaviour more, it opens up our window of
interventions.

← What we learn in class has much relevance to peoples’ everyday lives.

← Book: Canadian Institute of Health Info (download healthcare in
Canada article to see what drives healthcare here).
← www.cihi.com

← Get into the muddy water, otherwise we will just build policy bridges to
walk over it.

← Dialogue vs. Debate

dialogue debate
• We learn from each other
• Conducive to learning
• Year two onward involves
much dialogue and
thinking/speaking as to how
things are relevant

← Negotiation:
• In the 80’s when healthcare was full of funds
o Ex) having one car in a family of 6 requires various levels of
negotiation

← NEGOTIATION SKILLS FOR REGISTERED NURSES

← “There is not enough money in healthcare” is a scary topic when you
take it for granted and do not question it. As cutbacks and health care
reform change RN’s roles and HC structures conflict almost invariably arises.

← You can view conflicts as problems or learning opportunities.

← Conflict arises from:
• Unclear expectations about new positions. Therefore, when you get
a new position, look at the job description. This is your foundation
of practice stemming from the CNO.
o Poor communication between managers and staff.
 Lack of clear jurisdiction over changing responsibilities
(such as d/c planning with patient—who is responsible
for this?)
 Personal differences in approaches to nursing (do you
see patients as people or beds??). Your practice in
comparison to the CNO.
 Conflict between departments that struggle to maintain
their share of health-care dollar (such as Pharmacy
hours of operation in comparison to the 24 hour care
needed in hospitals).

← Friction can arise anywhere:
• At the individual or group level.
example: “I understand that Mrs. Jones didn’t get her bath today.
Can you explain this to me?” Go beyond the issue because this is a
human endeavour.
example: at the policy table, smoking cessation was a large conflict.
o Between shifts of RN’s
“Those people on nights…they don’t do anything.”
Talk to each other. Overlap shifts provide more fluid care.
Some start at 7, 10, 12 and they float from unit to unit.
o Between RNs and managers.
example: some hospitals, RNs may not feel they are listened
to.
o Nurse managers and administration—esp. if admin is really
into the managerialism model.

← In all cases RNs must deal with it.

← Strategies for dealing with conflict:
• Manage conflict by maintaining relationships ad developing
solutions that benefit all sides.
The best solution, not the perfect solution. There is a little
give and take, but it works.
example: care giver of an ill family member dies before the
chronically ill one does because they were trying to provide a
perfect solution for the other person…not themselves.
• In order to do this, we need good negotiation skills.

← THE NEGOTIATION PROCESS

• Cooperative and collaborative approaches result in more successful
resolutions of conflict.
example: “who is going to do the dishes, laundry this week?”

← Principles of the negotiation process:
• Understand your own motives as well as the motives of others and
try to maintain a problem-solving approaches.
example: Carla Holmolka and other sociopaths do not have this
ability.
o Focus on the issues rather than the people
 Maintain an open mind to opposing views by being
others-focused. This is part of maturity.
 Listen genuinely.
 Objectively identify the merits and drawbacks of the
alternatives. Keep yourself out of there!!
“If we did this…what would happen?”
critical thinking
“If we do not gown up OA’s before sending them to the
OR…what would happen? Hypothermia. How could we
work around this? We could use Velcro gowns to make
the other nurses’ lives easier”
 get heads together.
 Present arguments in ways that leave the other with
self-perceived benefits.

← The skill of negotiation requires complementary skills in
communication:

← It is the brick and mortar of every relationship. Even though when we
started this program, we felt like we could die from all of the communication
classes. Remember: 90% is non-verbal. You could read people without
even talking to them. For example: mothers could ground for something
before you even spoke 3 words.
• Explain the benefits of your ideas in a (+)ve way. This shows that
you have put some serious thought into it.
• Listen actively to the response. 3 part empathetic response. “Are
you saying this because of this? Is this how you feel?”
• Try to identify other peoples’ concerns and explain how those
concerns can be overcome
• Listen attentively to ideas, encourage elaboration, ask about
benefits and help to resolve obstacles. Mediation is an example of
this. Think of the presence of these traits in you on a daily basis.
• Trust, likeability, a sense of fairness.
example: don’t just solve things to last for two people, solve it to
benefit ALL people.

← Altruism is when you do things for people. Advocacy is when you
act on someone’s behalf when they are unable.

← Key concepts to negotiation:
• Communication—the transference of understanding (seek
feedback, provide rationale, provide positive feedback for others’
ideas, clear description of goals, empathy).
 sharing your knowledge on paper or in person.
• Consideration—the degree to which concern is exhibited,
individual needs and relationships are recognized, and democratic
opinions are sought. It entails actively eliciting others’ concerns
and opinions and seeking ways to attend to them.
“I can see this issue is really bothering you, and I care.”
• Commitment—involves an emotional and intellectual investment in
the process.
like your intimate relationships. When you find something, you
stick with it whether it is people or policy changes you would like to
see change.
• Persuasion—to sell your idea you must adjust your style, language
and emphasis of the presentation to each audience involved.
• Compliment and enlist the other person’s intelligence because
people are:
resourceful (not resources) and full of ideas.
Give credit.
• Lower the person’s defenses by engendering trust through
genuineness, dependability, competence and charisma.
aggressive (temper flares d/t lack of confidence to speak earlier,
may get violent, gossip)
assertion

← Negotiation with RNs, patient, other disciplines & the public.
← Media: health promotion campaigns in radio, TV, posters, billboards,
etc.
← Public: policy changes.
← Patient: pain management and attending P/T and limiting
degeneration, but you must talk to the person to know if they’re in pain…
don’t just leave them there.

← The context where we practice has to have conditions conducive to
negotiation (such as shared power).
← The structures such as policy committees we can join and have a
voice.

← More than ever before RNs need to be skilled at negotiation in order to
contend with the change and conflict in HC today.
← -complexity
← -tainted blood transfusion
← -pathologist with malpractice for 10 years while falsely- accusing
parents of wrongdoing.

← Carol Miller Functional Consequences Theory

← If risk factors related to aging changes are unidentified they will lead
to negative functional consequences. If they are identified then
interventions leads to positive functional consequences.

← Context:
• Models for care
• Focus for assessment
• Policies, systems (staffing)
• Structures
team
significant others
institution and community

← ID risks related to aging changesinterventionpositive f(x)al
consequences
← UnID age related changes (risks)negative functional consequences

• Theory/knowledge
• mid-range theory
• practice

← Older adults:
← Habits:
• smoking
• thrifty (turning heat down)

← Beliefs & myths:
• confusion
• incontinenceif they believe it’s normal they may not drink water
before they go out, therefore causing dehydration
• sexual dysfunction
• constipation & laxative usedehydration and loss of electrolytes;
loss of vitamins
• drugsif doctors cannot manage, self-prescribe; re-use antibiotics

← **YOU NEVER KNOW WHAT PPL BELIEVE UNTIL YOU TALK TO THEM**

← Environment
• hometemp, lighting, clutter, stairs, rugs, smoke alarms, carbon
monoxide, rotten food (loss of smell), hand washing, hygiene.
• LTCshared equipment, how dirty attends, etc are handled,
staffing.
• Hospital room exposure to open windows.
• Immediate envirofamily dynamics
• Agencypolicies that need to be changed; does staff know about
the pop. they are caring for?????? Model of care.
examples: water stations.
• Communitysmall interventions to provide safety
example: flashers for pedestrians to prevent collisions.
Pain In The Older Adult 14/04/2010 11:14:00
← Older adults and Pain

• Pain is very quiet in the sense that its not researched as much, not
always acknowledged etc. Some people call it the 5th vital sign, so
that people are always thinking about it and have it under their
nose.
• Comfort: Holistic. It is more than just about symptoms.
o It is a basic human need of Maslow’s hierarchy of needs; thus
it is fundamental and all higher levels of needs become
insignificant to the person in pain.
 Maslow’s hierarchy, he has comfort and pain in it at the
bottom, meaning that if those needs aren’t met, you
can’t move up. They are fundamental.
o Absence of physical pain is not always sufficient to provide
comfort.
• Pain: a multidimensial and pervasive phenomenon: a lot of it has
to do with meaning you give to it. It is holistic. I as sensory,
physical, psychological, motional, and spiritual components.
o Pain can be whatever the person experiencing it says it is.
Never judge, ask what it means to them. (It is their life, they
are making sense of it).
o One of the most common complaints of older adults. (Also
under reported, maybe people think is normal maybe people
are scared of what it might mean…)
← Consequences of Pain:
• Erodes personality. (normal aging changing should not change
personality, cognition etc)
• Sap our energy (Lack of energy can mean many things, very
complex. Pain may be one reason).
• Can manifests itself as an every-intensifying/present cycle of pain,
anxiety, and anguish until the cycle is broken. (Sometimes by us).
• You may see pain manifested as
o Depression, sleep disorders (like early morning awakenings),
eating disturbances, disturbances in socialization (people may
not be as joined to friends and activities, it can affect
relationships). Also can manifest itself as impaired mobility,
increased health care costs (we don’t manage pain well
according to research).
o Dramatic lifestyle changes (altered family relationships,
inability to visit friends.)
o People can go into shock from pain.

← Consequences of unrelieved pain
• Chronic pain as sometimes been given a negative label, or a
stereotype. People are sometimes scared of telling us they’re in
pain because they might be scared we’ll associated with
“malingering” (trying to get out of doing something, like work) or
that we may think they are looking for drugs, or that they have
psychological problems from the “chronic pain”.
o Some people therefore say that we should change the name
from chronic to persistent. Keep in mind that education must
go along with it, b/c even though we change a name, doesn’t
mean we change peoples attitudes about it.
• Serious physiological problems: hypertension, tachycardia, heart
damage (if they have heart problems already, and pain adds on top
of it). Depression, anxiety, may not want to participate in
rehab/self care because of the pain, increasing recovery time. This
lowers quality of life and increases health care costs.

← Pain is sometimes considered the 5th vital sign.

• Factors that affect out definitions or interpretations of pain and/or
our response to it:
o Experiences: maybe we have a igher threshold bc of life
experiences etc.
o Our histories: cultural, group, family, gender, peer
expectation etc.
o Meaning we give to pain: Where pain is: can be referred.
Cause is not necessarily under the location of pain.
• Our responses to pain are affected by:
o Cultural expectations
o Acceptable behaviours (ie gendered expectations…)
o Ethically diverse responses from social modeling, group
pressure and our families
o Values
o Experiences with pain
o Myths and stereotypes

*Many people, especially older adults suffer from unrelieved pain.

← Many factors contribute to under-diagnosis and under-treatment of


pan
• Barriers to recognition, assessment, and/or treatment of pain:
o Nurses and client all believe myths, have different beliefs.
(Don’t want them to get hooked etc.)
o Many chronic conditions going on, and one pain may be
missed. Can be tricky to manage everything.
o Older adults might have cognitive impairment from any
number of causes (dehydration, meds…) this makes
assessment of pain very tricky.
o Some health providers even seem to think that the cognitively
impaired don’t feel pain, or feel it in the same way.
o Mental pain, psychological pain that people may feel due to
loss of spouse, death of friends, loss of house… they may not
report this because they are worried about the stigma that
they are complainers, or aren’t strong enough…
o Maybe cannot report the pain because loss of verbal skills
(expressive aphagia) they can understand everything you’re
doing/saying but cannot tell you they are in pain.
o May have sensory impairment which interferes with their
ability tot ell you about pain.
o Health care providers lack knowledge of pain management.
They fear pain, fear us of narcotics, fear side effects of pain
management.
o Health care providers may not be paid for thorough pain
assessment (may not be reimbursable) so they may not take
the time to do it.
o Pain management is poorly taught in some medical schools.
o Family perceptions (take a med for pain, may get a bit
confused and so family gets angry and won’t let them take
it).
← Prevalence of pain in older adults:
• Some say in community pain is twice as prevalent in older adults
than in younger population.
• Community dwelling older adults: 25-50% have unrelieved pain.
• Long term care settings: 45-80% older adults have under treated
pain.
← Reasons why older adult may be at risk for pain-inducing pain:
• Lived longer: more change of having disease or injury that induces
pain (arthritis, hip fracture…)
• Some older adults may have 2 or 3 underlying conditions that cause
pain, and one might be missed, so pain not treated.
• Older adults are more prone to accidents (due to our care
sometimes) medications that can cause confusions, falls…
• When an accident like a hip fracture, sprain, hematoma etc, it takes
longer to heal. Thus pain may last longer.
• Loneliness and emotional pain from loss.
• Depression or boredom can decrease ability to cope with pain.
Types of pain:
• Acute pain
o Temporary, its time limit. Easily controlled by analgesic
medication. Usually know you’re going to get relief. Like post
op pain (can be hard with older adults, much more complex
b/c meds, confusions…)
• Chronic/persistent pain:
o Multifactorial: may see manifested by depression, eating or
sleeping disorders with persistent pain underlying it, may
come with impaired function. (old man is 93, is a veteran)
Few over Germany. Came back from war, fell off train and
has had sore leg ever since. Swims lot still etc. Decided he
was really sick of pain, so went for surgery (people said he
was too old, still went). Has had a brace for months. Now its
off and he’s better.) We have to make sense of this, people
may not be able to go on, even if omeone is old, maybe they
should get help

Effects of persistent/chronic pain: (remember it is holistic)


o Categorized as either nonmalignant origin or malignant origin.
 Intractable nonmalignant pain: have not made it better.
It is the most common kind in older adults.

Causes of non-malignant pain in older adults: *** won’t be on exam


• temporal arteritis (pain in tempral area)
• osteoarthritis
• rheumatoid arthritis
• Lumbar disc disease (back pain)
• Lumbar stenosis (nerve coming onto vertebrae gets crimped.
Shooting pain.)
• Osteoporosis (one lady lost 6 inches in height)
• Peripheral vascular disease (can cause ulcers etc)
• Trigeminal neraulgia (nerve pain)
• Herpes Zoster (shingles)
• Post herpetic neuralgia (after shingles in over nerve pain)
• Diabetic neuropathy (nerve pain from diabetes)
• Phantom pain (after amputation)
• Angina (heart pain, chest pain)
• Post mastectomy pain (after breast removal, may have swollen
arms, lymph…)
• Hiatal (sp?) hernia (above cardiac sphincter usually)
• Irritable bowel syndrome
• Acute cholecystitis (gallbladder pain)

Persistent pain can be further classified as:
• Nociceptive pain:
o Responds well to analgesics and non drug interventions.
o Causes: injury of muscle, bone, mucosa, skin. Most often
results form stimulation of pain receptors. Tissue
inflammation (cellulites). Burns (not 3rd degree, usually too
deep so nerves are burnt), falls. Infection anywhere. Joint
pain. Ulcers. Internal organs, distension obstruction.
(Pancreatitis, appendicitis… can be under different
classifications though). Tumors. Visceral pain.
• Neuropathic pain:
o Peripheral nerves of CNS.
o Causes: post herpetic neuralgia. Trigeminal neuralgia. Post
stroke pain. Post amputation pain (phantom pain). Diabetic
neuropathy. Spinal stenosis.
o Tends to feel like stabbing, burning, tingling, shooting pain.
o Don’t respond as well to conventional analgesics.
Antidepressant medications sometimes help with this kind of
pain, anticonvulsant meds also seem to help.
• Mixed/unspecified:
o Examples: headaches can be a mixed. Compression fracture
can be bone and pinched nerve. Good to know this because it
can alter treatments.

← Another way to classify pain: *** not on test

• Cutaneous pain (or subcutaneous): puncture, skin wound, sliver
etc.
• Somatic: “the body all” under the subQ: bones, ligmanets,
tendons, muscles, deep faschia.
• Visceral: organs

← Most common source of pain in adults is musculoskeletal. Many also
have neuropathic pain. (post herpetic neuralgia etc).
← Remember that cognitively impaired people feel pain. If it would hurt
you, it hurts them. Pay attention to cues that may suggest pain. Read that
person. Ask people who know them better, family, significant other to help
understand behaviour and give meaning to that behaviour. Some people
suffer in silence because health care providers don’t do anything about it.

← Cues by patients:
• Overt behaviours
o Grimace
o Aggression
o Irritability
o Striking out (may just hurt so much)
o Physical movements:
 restlessness (could be pain, lack of oxygen, full
bladder… big concept with lots of causes. We need to
make sure it’s the right one).
 Drawing les up in fetal position.
 Repetitive movements.
 Cautious movements.
 Not turning whole body (less flexible).
o Changes in ADLs.
• Sounds people make. (groan, moan, silence, yell, scream, cry…)
• Appearance:
o Facial expression, or lack of it. Wincing, grimacing.
o Complexion.
o Perpsiration

← Assessing pain:
• A comprehensive assessment f pain includes:
o A complete history
o A complete physical
o Specific assessment around the pain
 OA’s self-report of pain: their story. This is crucial.
 Regularly ask about their pain ad assess it
systematically.
 Ask hem specific questions: Do you have pain today or
not? Where is it? Is it every day or not?
 Use different works, allow the to use their own. Ie:
achy, hurt, like a knife in my chest, discomfort.
 Additional cues about pain in OAs
 Overt behaviour
• Aggression
• Physical movements
• ADLs
 Sounds
• Verbalizations (what they tell you)
• Vocalizations (moaning, groaning)
 Appearance
• Facial expression
• Body language
o Detailed questions about pain:
 Onset
 Duration (variants in it etc)
 Rhythm (do they know when its going ot happen again,
unpredictable)
 Intensity (scale)
 Frequency (every hour, every day..)
 Quality (In older adults (OA) own words: e: prick, ache,
burn, throb, pull, sharp…)
 Location (remember can be radiating. Where its
hurting doesn’t man that’s where its coming from)
 Characteristics
 Manner of expressing pain (how they usually show you
they are in pain, same staffing helps.)
 Causative or aggravating factors (it could be right after
family visitor left. Maybe that causes the pain, you
never know what happens in families.)
 Alleviating/relieving factors: very powerful. (taking
aspirin themselves, maybe they are at risk for other
things now etc)
 Treatment previously tried
Effects of pain
 What’s their normal function and has that changed now.
Decreased quality of life
 Accompany in symptoms: nausea
 Sleep (what wake syou up?)
 Appetite
 Physical activity (such pain can’t even walk entire
room).
 Relationships with others (ie: guilt b/c they yelled at
loved one but they’re not themselves).
 Emotions (men don’t cry, anger, suicidal thoughts,
crying…)
 Concentration
 Other
 Social support

o Medication history, including Over the counter drugs


o Screening for:
 Cognitive impairment
 Depression
 Quality of life
 Indicators of function, nutrition, sleep, involvement in
social activities
o Assessment of pain during activity (ie: physical therapy)
o Iatrogenic disturbance pain: pain that ca be caused by care
providers
 Examples: use a 5-day IDP (iatrogenic disturbance
pain) tracking sheet
 Check their pain for movement etc
o Pain rating scales:
 Examples: different kinds: 1-10, happy/sad faces etc.
← Interventions
• Holistic
• Non-drug therapy
• Pharmacological Measures
o General principles of pain control of OAs are the same as for
younger adults; however OAs may experience more adverse
drug reactions
o In addition, some drugs used in younger adults (like Demerol:
when its broken down, metabolites do something funky) are
contraindicated in older adults. See BEERS list for
contraindicated meds.
o A few General principles:
 With opioids: start with the low dose and increase only
VERY SLOWLY to desired dose.
 Some drugs may need to do creatinine clearance to find
what dose to start at
 Analgesics and opioids use around the clock dose to
prevent pain
 Try to choose meds with the fewest side effects (lady in
hospital is given narcotic, respiratory rate drops down
to 8. Luckily student checked back in a few minutes he
pulled emergency bell, nurse corrected it with new med.
What if he hadn’t checked? The patient had forgotten to
mention that she couldn’t have this drug, so it wasn’t
on charts etc. Always check for interactions.)
***Equianalgesic potency table: good to know this table b/c it lets
you know the comparitavely potency of drugs. Example: morphine is
6x as strong as codeine. Hydromorphne is 5x stronger than morphine.
Oxycodone is 2x s strong as morphine.

o Various analgesics (nonnarcotic and narcotic) as well as


adjuvant medications:
*** WHO has a pain ladder: suggests ladder for pain
Mild pain: non-opioid + adjuvant therapies
Mild/Moderate: use opioids + non opiiods +/- adjuvant
Severe pain. Opiod meds, +/- non-opioid, +- adjuvant therapy.

Non-opioid analgesics: THIS WONT BE ON TEST


o acetaminophen (tylonol) , NSAIDS, topical
o If acetaminophen is not effective or is not tolereated,
monacetylated salicylates (trisalytes, choline magnesium) ma
b effective, or use ones of many. NSAIDS available (aspirin,
ibuprofen)
o Cetaminophen and NSAIDS must be used with caution
because of increased risk of adverse effects (ie: GI bleeding,
and renal and hepatic impairment).
 NSAIDS can also potentate and increase or decrease
the effect of many prescription medications that OAs
may take.
Opioid analgesics: NOT ON TEST
o Used with acute pain, as will as both malignant (cancer) and
nonmalignant persistent pain.
o Recommendations: start with lowest anticipated effective
dose, monitor response frequently, and tirate slowly to
desired effect.
o Opioids that are safe to use with older adults:
 MorphineOxycodone
 Hydrocodone
 Hydromorphone
 Transdermal fentanyl
 Most others are not recommended for older adults
because of poisonous metabolites when broken down.
 Demerol, Talwin, Tramadol, Methadone,
Propoxyphene (Darvon)
o
Adjuvant drugs:
o Nerve pains, depression, shingles, arthritis pain, before
putting IV in to dull pain…
 antidepressants and anticonvulsants
 topical analgesics
 muscle relaxants
 anti anxiety medications
 medications to dry secretions (Lou Garrigs Disease ALS)
 Antipruritis (anti-itching: liver disease makes skin itchy)
 Diuretics
 Magic mouthwash (inflammation of oral mucosa from
things like chemo)

Older Adult Nursing 14/04/2010 11:14:00
← Groups:
• Primary Group:
o Intimate groups, family, children, friends
• Secondary Group
o Work groups, class, less personal groups

← Formal groups – secondary groups (task oriented)
← Semi-formal groups – friends, meets social needs (church groups,
sport teams etc)
← Informal groups – family, hobbies, friends

← 8 Factors Affecting Group Dynamics:
• Norms
o Rules set for a group
o Well organized, good structure = good overall group
functioning
• Commitment
o An obligation one feels to do something, or to follow a course
of action
o Conflicts can arise so commitment is important – all members
agree and commit to their role
o Strong sense of belonging – enjoy each other, differences,
getting together – support is evident amongst members as
well
o Wants to do a task, and do it well
o Giving positive feedback
• Leadership style
o Leaders dictate how the group functions
o Autocratic
 Dictator
 Works well with simple, day to day decisions
o Democratic
 Facilitator
 Decisions occur in the group
o Laissez-fairez
 Leader is there if there is a problem – intervenes when
team cannot handle an issue
 Works well if each persons role is defined and member
is knowledgeable about their role/job
o Situational
 Draws on strengths/leadership depending on what is
being worked on – new leader every meeting type thing
• Decision making methods
o Individual
 Leader makes decisions and everybody is expected to
abide by it
 Works for simple, routine things
o Minority
 Few members of group meet/discuss and make a
decision
 Only works if all group members cannot get together
 Everybody has to agree/commit to what the minority
group decides
 Doesn’t work well for very important issues
o Majority
 51% of the vote (at least half of all members make the
decision)
o Consensus
 Everyone discusses an issue (all points brought up) and
a plan of action is agreed upon
 Not everybody is committed fully, but everybody is to
some extent
o Unanimous
 Everybody needs to commit (Jury, War etc)
• Member behaviours
o Refer to group project handout
• Interactive patterns
o Sitting in a circle, communication is best, everyone is equal
o How people are seated
• Cohesiveness
o Degree of unity that the group feels overall – if cohesive then
the group is unified
o Members like each other, are friendly, share similar
opinions/attitude, supportive, can influence others because
egos are under control-praise each other
o Accepts tasks and rules, and does them to the best of their
ability
o Trust
o Similar opinions
• Power
o Power struggle – associated with a poor self-concept and a
weak ego
o Legitimate positional power- unit manager, head nurse
o Reward power- be nice to someone who can reward you
o Charismatic power
o To control it, change leaders, assign different roles etc

← Interpersonal communication is the most important form of
communication.
• Trust, honesty, respect, reliability are all things that contribute to
good interpersonal communication
• Noise- personal, emotional business that effects our communication

← Relationships

← Maintaining meaningful interpersonal relationships takes a lot of work.
There are always at least 2 people involved – and everybody has different
roles. With successful interpersonal communication, come successful and
more positive lives.

← Escalation of relationships:

← 1) Pre-interaction awareness
• Noticing someone – positive, attractive etc
• Attracted by positive self image
• Automatically present self in positive manner (avoid sarcasm and
don’t give false information, we do not interrogate)

← 2) Initiation

← 3) Exploration
• Getting to know each other better
• Likes/dislikes

← 4) Intensification

← 5) Intimacy

← This is difficult to maintain, and if not careful will de-escalate. Honesty,
proper communication and openness is important in maintaining a
relationship – and it is hard because it takes courage. Before getting into a
serious relationship you need to find out what the person is all about.

← When relationships start to get sloppy, people get a little lazy in things
they used to do, begin to push each others buttons (teasing etc), not
apologizing, becoming disrespectful, becoming less interested in sex (mate
relationships – less intimacy). Remember, open and honest communication
should be practiced.

← De-escalation of relationships:

← 1) Turmoil of Stagnation
• fighting, getting bored, not exciting
• friends or lovers: DO SOMETHING!

← 2) De-intensification
• furthers the de-escalation by the relationship not being as intense

← 3) Individualization
• things start to be more about yourself, rather than the people
involved in the relationship

← 4) Separation
• bye bye

← 5) Post-interaction effects
• rough break up, depression etc

← Communication

← Three factors that affect communication:
• Physical factors (PATTS)
o Personal space (proxemics)
 Intimate space (contact to 1-1.5 ft)
 Nursing: assessment, grieving, holding babies,
blind people, washing people
 Personal space (contact to 1.5-4 ft)
 See the person more, less aware of body scents
etc
 Nursing: greeting client, entering clients room,
introductions, health teaching, interviewing
 Social space (4-12 ft)
 See whole person, body odour not aware, eye
contact – can see all, speak louder to ensure
hearing, more formal and less intimate
 Nursing: teaching a group, social actions
 Public distance (large distance)
 Loud, clear, annunciated speaking
 Nursing: teaching, giving a speech
o Ability of communication
 Ability to speak, hear, see and understand what is being
said
 Nursing: brain damage, blind/deaf, stroke, different
language, someone under the influence
o Timing
 Nursing: teaching – appropriate time (ie/ coma, recent
diagnosis etc)
o Territoriality
 Nursing: show respect (ie/ going thru people’s things –
Can I look in your drawer for your soap?)
o Setting
 Where you are, appropriateness, respecting privacy
• Psychological factors (RAPE)
o Roles, relationships
 How we communicate varies throughout the day, and
with whom.
o Attitudes
 Positive (warmth [friendly, kind, considerate – smiling
and laughing], caring [convey a meaning of emotional
closeness, genuine concern, requires more
psychological energy], respect [emphasizes individual
worth, listening, being open minded], acceptance
[receive honest feelings/actions without judgment]) and
negative (condescension [conveys superiority], lack
of interest, coldness) – communicated quickly (either
verbally or nonverbally)
o Perceptions
 Our perceptions can be different – depends on
personality, life experiences, culture etc
 Interpersonal perception is the process in which we
determine what people are like, and we give meaning to
their actions
 We make judgments about personality from what we
observe and perceive
 We decide what people are like (and if we like them or
not), we simplify (prototype and stereotype)
 Halo & horn effect
 We ignore detail
 We overgeneralize
 We ignore circumstances
 We tend to focus on the negative, rather than the
positive
o Emotions and self-esteems
 Noise is the emotional factor that effects communication
 It is what we think and feel during communication that
interferes with abilities to listen and interpret accurately
 Stop, look and listen (be other-focused and de-
centre!)
 Be sensitive to thoughts/feelings of other people
(most IMPORTANT thing for interpersonal
communication) – other-focused
 De-centre – think of the other person (How are
they interpreting? What’s their perception?)
 Emotion is the #1 killer of communication – get control
of it
 Self-concept (subjective description of who you are –
beliefs, attitudes, values, likes etc)
 Cognized Self: how I see me
 Other self: how others see me
 Ideal self: how I would like to be
 Components:
• ID (material self – body image)
• EGO (social self – role performance)
• SUPEREGO (personal identity – spiritual self
& self-esteem)
 Self-esteem (evaluation of your worth – based on skill,
talent, experience etc – how you feel about yourself)
 Act as filters when responding/perceiving
messages & situations
 Low self esteem:
← Non assertive, personal putdowns, control others, aggressiveness,
poor interpersonal relationships, defensive, poor coping and problem solving
• Improvements can be made by dwelling on
the positive (not negative), practicing
reframing, not dwelling on the past,
developing honest relationships, not
comparing yourself to others
 Shyness is a serious issue that can affect
communication – a discomfort that inhibits
interpersonal situations, it is routed in childhood (things
developed in childhood are hardest things to change)
 Difficult social situations, less verbal, less
interested, high levels of being self-conscious,
negative thoughts about themselves
• Cultural factor

← Conflict

← Problems arise when feeling pressure, anxiety or perceived sense of


failure. It affects self-esteem. We need to handle ourselves in appropriate
and professional ways in order to deal with problems.

← 1) Refrain
• It’s not the end of the world
• Stop, look, listen – deal with the situation (get control)
• Don’t respond emotionally – deal with the facts only
• Figure out the issue – why is it happening?
• What are the other perceptions?

← Once the problems are identified – figure out how to fix it. If it’s
escalating, walk away. Once able, talk the situation over – 1 to 1. Explain
and get perceptions. Listen carefully, keep conversation positive.

← If two people cannot work out the probem, it should then be taken to
someone else (ie/ boss, academic advisor). Must go together.

← Conflict is a struggle, when two people cannot agree on how to meet
their needs. Types:
• Simple conflict (pseudo conflict)
o Misunderstanding
o Little fight
o Two people disagree on how to achieve goals
o Compromise/collaborative to fix
• Ego conflict
o Person feels personally attacked
• Constructive conflict
o Good conflict
o Not fighting dirty
o Build relationship better
• Destructive conflict:
o Destroys relationship
o Both people dissatisfied at the end

← Stages of conflict:
• Prior conditions:
o Realize that someone’s behaviour is bothering you
• Frustration-awareness stage:
o Someone says they are frustrated/mad
• Active conflict stage:
o If not dealt with, and active conflict occurs
o Struggle, talking about problems
• Resolution stage:
o Find out ways to manage it, fix it
o What’s wrong, my goals etc
• Follow up stage:
o Check to make sure things are now working
← Is everything alright?