CARE OF CHRONICALLY ILL AND OLDER CLIENTS - Older adults

o Life expectancy: year 2000 = 75 yrs old

Chronic conditions
o As one ages, diagnoses of chronic disorders frequently multiples
- Medical conditions or health problems with associated symptoms or disabilities o Longer life expectancy
that require long term (3 months) or longer treatment  Periods of disability, vulnerability to other health problems,
- The irreversible presence, accumulation, latency or disease states or impairments financial expense, increasing care concern
that involve the total human environment for supportive care, self-care, o Accounts for significant portion of health care cost
maintenance of function, and prevention of further disability.
Characteristics of Chronic Conditions (p.147)
Disease vs. Illness
1. Has associated psychological and social problems
Disease: a condition that the practitioner views from a pathophysiological model; 2. Usually involve many different phases over the course of a person’s lifetime.
health practitioner’s point of v view 3. Requires persistent adherence to therapeutic regimens to keep chronic conditions
Illness: the human experience of symptoms and suffering, and refers to how the under control
disease is perceived, lived with and responded to by the individuals and their 4. One chronic disease can lead to the development of other chronic conditions
families. 5. Chronic illness affects the whole family
6. Major responsibility for the day-to-day management of illness falls upon the
Acute Chronic shoulders of chronically ill people and their families.
- Sudden in onset with s/sx related to - Can appear suddenly or through 7. Management of chronic conditions is a process of discovery
the diseases process itself insidious process
8. Managing chronic conditions is a collaborative process
- Ends in relatively short time, either - Have episodic flare ups or
with recovery and resumption of exacerbations that remain for 9. Management of chronic conditions is expensive
prior activitites, or with death months 10. Raise difficult ethical issues to the patient, health care professionals, and society.
11. Living with chronic illness means living with uncertainty.

Impact of Chronic Illness to G&D Phases of Chronic Illness

- Infancy through adolescence 1. Pre-trajectory phase: at risk

o Very young: maybe unable to work at self-sufficiency task 2. Trajectory: s/sx
- School age 3. Stable phase: under control
o May be unable to stay abreast of school work/participate school activities 4. Unstable phase: exacerbation
- Adolescents and young adults 5. Acute phase: complication
o May have obstacles that prevent them from reaching their goals and 6. Crisis phase: life-threatening
becoming independent 7. Comeback: recovery with limitation
- Young to middle-aged adults 8. Downward phase: decline
o Chronic condition can complicate conception and completion of goals and 9. Dying phase:
dreams
Phenomenon of Aging 8. Diabetes Mellitus
9. Disease of the nervous system or sense organs
Demographic theories of Aging 10. Prostate Hyperplasia
- Longer life spans Top 12 Causes of Death in Older adults
- Fastest growing age group is 85 years and over
1. Heart disease
Demographic Issues 2. Cancer
1. Utilization of Health Care resources 3. Cerebrovascular disease
a. Older populations utilize health care services at rates that are 4. Chronic Obstructive Pulmonary Disease & assoc. conditions
disproportionate to their overall representation in the population 5. Pneumonia and influenza
b. They are hospitalized more frequently, suffer from more chronic conditions 6. Dm
2. Other demographic issues 7. Accidents
a. Increasingly diverse ethnically, racially and culturally 8. Alzheimer’s Disease
b. Poverty is a significant consideration 9. Kidney Disease
10. Septicemia
Top 8 Most prevalent chronic conditions among older adults 11. Atherosclerosis
12. Hypertension
1. Arthritis
2. Hypertension Other Characteristics of Elders
3. Heart disease
4. Respiratory Disease - Ethnicity
5. Diabetes Mellitus o Number of minority elders increasing
6. Cancer o Elder Hispanic fastest growing subpopulation
7. Cerebrovascular Disease - Socioeconomic
8. Atherosclerosis o Women have longer life expectancy
o Men more likely to remarry
Top 10 Leading causes of hospitalization o Educational level gradually increasing
o Lower incomes
1. Heart disease
2. Cancer o Most live in community settings
3. Cerebrovascular Disease o Poverty level more likely when living alone
4. Pneumonia - Health
5. Fractures o Chronic health problems and disabilities
6. Bronchitis
7. Osteoarthritis
 iii. All things in moderation
iv. Longevity maximized by avoidance of excess
Theories of Aging v. Longevity may also be maximized by avoidance of abstinence
a. Biological vi. Jeanne Calment. Lived to 124 died several years ago. Smoked cigars
a. Genetic theories to 110. Drank champagne until she died  rock on lola jeanne
i. Life expectancy is pre-programmed b. Sociologic
ii. Cells divide at limited number of times a. Disengagement theory (Cumming and Henry)
iii. Aging as a result of mutation of somatic cells or alteration in DNA i. Mutual withdrawal between older and elder’s environment
repair mechanisms b. Activity theory (Havighurts)
b. Wear and tear i. Best way to age is to stay physically and mentally active;
i. Use and destruction c. Continuity theory (Atchley)
c. Immunity i. People maintain adult values, habits, and behaviors as they age
i. Changes in the T-lymphocyte d. Subculture theory (Rose)
d. Cross-linkage i. States that old people as a group have their own norms,
i. Proteins become cross-linked expectations, beliefs and habits therefore, they have their own
e. Free radical theory subculture
i. Free radicals damage cells e. Age stratification (Riley)
f. Neuroendocrine theories i. Society age in groups that change and influence each other
i. Changes in the brain and endocrine glands cause aging showing interdependence
g. Apoptosis theory f. Person: envirionment fit theory (Lawton)
i. Apoptotic program is dysregulated i. Person’s competencies change with aging thus affecting het
ii. Precipitate disability and degeneration person’s ability to interrelate with the environment
h. Longevity and senescence theories Pyschologic Theories
i. Factors that contribulte to healthy aging
1. Genetic Erik Erikson
2. Physical Environment
- Integrity vs. Despair (65 to death)
3. Physical activity and throughout life
4. Consumption of moderate alcohol - Sense of loss, contempt for others
- Greater the task achievement the healthier the personality
5. Sexual activity persisting into advanced years
6. Dietary - Failure influences the person’s ability to achieve the next task
- Failure to resolve the crisis is damaging to the ego.
7. Social environment (status of wisdom)
8. Dignity Robert Peck
ii. Senescence: when death of older people cannot be ascribed to a
disease process, cause of death be listed as senescence - Ego differentiation vs. work role preoccupation
 o Occupational work is not the basis for self definition and worth o Exam table-padded, head part able to rise
- Body transcendence vs. body preoccupation o Noise free
o The inner self- not the body is viewed as the basis for satisfaction, - PA at the clients own pace
happiness and morale - Organize exam- minimize change in position
- Ego transcendence vs. ego preoccupation - Establish non-threatening relationships
o Acceptance without undue fear and anxiety of death; active involvement in - Promote respect- address by their last name
a future beyond morality - Allow to respond to questions
- Face the client while speaking
Havighurst ( 65-75) - If w/ hearing aid, make sure it’s functional
- Adjusting to - Visually impaired- allow to wear glasses and use visusal cures
o Decreasing physical strength - Geriatric team approach: recommended
- Include education on screening techniques
o Retirement
- Recognize cultural differences
o Lower and fixed income
o Death of parents, spouses and friends Issues in Physical Assessment
o New relationships with adult children
o Leisure time - Adjust sensory deficits, with as little glare, direct light, and background noise as
o Slower physical and cognitive responses possible
- Keeping active and involved - Be attentive to older adults’ body language, which may signify fatigue, anxiety,
- Making satisfying living arrangements some degree of cognitive impairment, or a need to void
- Employ an age-appropriate approach
(75- older) - Eliciting a complete history from an older person may take longer than for a
younger person
- Adjusting to
- How would you prepare for physical examination an older adult with hearing
o Living alone
impairment and severe COPD?
o Possibility of moving into a nursing home - What specialized equipment would you need in the room and what adaptations to
o One’s own death the environment would need to be considered?
- Safeguarding physical and mental health
- Remaining in touch with other family members Older Adults Common Health Problems
- Finding meaning in life
- Injuries
Techniques for Geriatric Assessment - Chronic disabling illnesses
- Drug use and misuse
- Prepare the environment to compensate physiological and psychological changes - Alcoholism
o Comfortable and warm, minimal exposure - Dementia
o Straight backed chair: arms cushioned, not too low - Elder abuse
 - Use of non-perfumed soap
- Application of emollient

Dehydration
Physiological Changes with Aging
- Tenting of skin is normal with aging. Hand not a reliable indicator of dehydration
Dermatologic - Use abdomen/forehead
Structural changes Clinical implication
- Delirium is frequently caused by dehydration and may accompany UTI.
Thinning of epidermis - Increased wrinkling
- Dry appearance Pressure Ulcers
- Uneven pigmentation
- Susceptible to infection when break - Localized ulcerations of the skin or deeper structures
occurs - Areas susceptible
Thinning of dermis: decreased vascularity - Decreased elasticity
- Pressure of 70 mmHg applied for longer than 2 hours can produce tissue
- Increased wrinkling
- Vulnerable to trauma destruction
- Decreased body templ regulation
Stages of Pressure Ulcers
Decrease in amount of subcutaneous fat - Sagging of skin
- Decreased fat pads on soles of feet, I- Nonblanching macule that may appear red or violet
which may impair ambulation;
II- Skin breakdown as far as the dermis
increase chance for pressure ulcers
Changes in adnexal structures: sebaceous - Decreased sweating III- Skin breakdown into the subcutaneous tissue
and sweat glands - Decreased growth of hair IV- Penetrates bone, muscle, or joint
- Decreased nail growth
- Thinning and graying of hair Nursing Interventions:
susceptibility to infection
1. Prevent pressure ulcers development (meticulous skin care and positioning)
Changes in neurosensory function - Potential for injury
2. Avoid elevation of head of bed greater than 30 degrees
3. Reposition every 2 hours
Nursing Implications: 4. Use an alternating-pressure mattress or air-fluidized bed
5. Use normal saline for cleaning and disinfecting wounds
1. Skin care: gently stimulate non-reddened intact skin sits with massage
6. Apply well-to-dry dressings as directed; or assist with surgical debridement
a. Avoiding the use of hot water and limit the use of soap
7. Cover the wound with a protective dressing (i.e. hydrogel dressings)
2. For immobile patients, consistent repositioning is essential (q 30)
8. Obtain wound cultures and apply topical antibiotics.
3. Keeping bed linens clean, dry, and wrinkle free.

Treatment for Xerosis (extreme dryness)

- Drinking 2L of liquid daily

- Total body immersion in warm water (32.2-40.6 C) for 10min.