CU12: Research Agenda on Aging
A. National: NIH Publication – 2030 Problems on Caring for
Aging Baby Boomers
Objective
To assess the coming challenges of caring for large numbers of
frail elderly as the Baby Boom generation ages.
Study Setting
A review of economic and demographic data as well as simulations
of projected socioeconomic and demographic patterns in the year
2030 form the basis of a review of the challenges related to caring
for seniors that need to be faced by society.
Study Design
A series of analyses are used to consider the challenges related to
caring for elders in the year 2030:
1. Measures of macroeconomic burden are developed and
analyzed,
2. The literatures on trends in disability, payment approaches for
long-term care, healthy aging, and cultural views of aging are
analyzed and synthesized, and
3. Simulations of future income and assets patterns of the Baby
Boom generation are developed.
Principal Findings
The economic burden of aging in 2030 should be no greater than
the economic burden associated with raising large numbers of
baby boom children in the 1960s. The real challenges of caring for
the elderly in 2030 will involve:
1. Making sure society develops payment and insurance
systems for long-term care that work better than existing ones,
2. Taking advantage of advances in medicine and behavioral
health to keep the elderly as healthy and active as possible,
3. Changing the way society organizes community services so
that care is more accessible, and
4. Altering the cultural view of aging to make sure all ages are
integrated into the fabric of community life.
Conclusions
To meet the long-term care needs of Baby Boomers, social and
public policy changes must begin soon. Meeting the financial and
social service burdens of growing numbers of elders will not be a
daunting task if necessary, changes are made now rather than
when Baby Boomers actually need long-term care.
Keywords: Long-term care, financing, Baby Boomers,
community-based delivery system
A major public policy concern in the long-term care field is the
potential burden an aging society will place on the care-giving
system and public finances. The “2030 problem” involves the
challenge of assuring that sufficient resources and an effective
service system are available in thirty years, when the elderly
population is twice what it is today. Much of this growth will be
prompted by the aging of the Baby Boomers, who in 2030 will be
aged 66 to 84—the “young old”—and will number 61 million people.
In addition to the Baby Boomers, those born prior to 1946—the
“oldest old”—will number 9million people in 2030.
This paper assesses the economic dimensions of the 2030
problem. The first half of the paper reviews the literature and logic
that suggest that aging in general, and long-term care services in
particular, will represent an overwhelming economic burden on
society by 2030. Then, a new analysis of burden is presented to
suggest that aggregate resources should not be a major issue for
the midcentury economy. Finally, the paper presents four key
challenges that represent the real economic burden of long-term
care in the twenty-first century. These challenges are significant
but different from macro cost issues.
What type of economic burden might be considered
overwhelming? Existing literature never explicitly defines this but
the sense is that the burden might be considered overwhelming if:
a. Tax rates need to be raised dramatically,
b. Economic growth is retarded due to high service costs that
preclude other social investments, or
c. The general well-being of future generations of workers is
worse than that of current workers due to service costs and
income transfers.
The discussion has significant implications for public policy and for
private actors focused on developing an effective care system for
the mid–twenty-first century. Public policy goals related to an aging
society must balance the need to provide adequate services and
transfers with an interest in maintaining the economic and social
well-being of the nonelderly. The economic challenges discussed
are such that public and private progress that begins in the near
future will make the future burden substantially easier to handle.
B. International: UN Program on Aging
The UN Programme on Ageing is part of the Division for Inclusive
Social Development (DISD), United Nations Department of
Economic and Social Affairs (UNDESA).
It is the focal point within the United Nations system on matters
related to ageing. As the focal point, its primary action is to facilitate
and promote the Madrid International Plan of Action on Ageing,
including designing guidelines for policy development and
implementation; advocating means to mainstream ageing issues
into development agendas; engaging in dialogue with civil society
and the private sector; and information exchange.
Expert Group Meeting on Global ageing and the data revolution
Population ageing has profound implications for many facets of
human life. An ageing population will affect everything from
economies, labor markets to health and social care. This prospect
requires a better understanding of the implications and possibilities
posed by population ageing as well as the situation of older
persons themselves. While the older population is growing at an
accelerated speed, many gaps in ageing related statistics and data
exist, affecting the ability to develop targeted policies and programs
that address ageing related challenges.
Recently, demand for evidence-based data and statistics on older
persons has been generated by the negotiations on the Post-2015
Development Agenda. In order to implement a comprehensive
Post-2015 Development Agenda, efforts to define a strategic
framework for statistics under the so called ‘transformative agenda
for statistics’, point at integrating and broadening the scope of
statistics and data collection. The agenda introduces innovations
to incorporate non-traditional sources that so far have not been
utilized in official statistics. These developments provide an
opportunity for addressing the gaps and needs posed by ageing.
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In this context, the Focal Point on Ageing is organizing an Expert
Group Meeting on “Global ageing and the data revolution – the
way forward in the post-2015 environment” in New York on 7-9
July 2015. The meeting aims at exploring how and which new and
non-traditional data sources can support the policy and programme
development on ageing issues. The outcome of the EGM seeks
responds to the need for sound ageing related statistics and data
as well as the needs that will arise from the targets contained in the
Sustainable Development Goals and the Post-2015 environment.
DESCRIPTION
The concept of National Sustainable Development Strategy
(NSDS) was proposed in 1992 in Agenda 21 (§ 8.7) where
countries were called upon to integrate economic, social and
environmental objectives into one strategically focused blueprint
for action at the national level. The NSDS “should be developed
through the widest possible participation”. And it “should be based
on a thorough assessment of the current situation and initiatives”.
In the Programme for the Future Implementation of Agenda 21
adopted at the 19th Special Session of the General Assembly (23-
28 June 1997), member States reaffirmed the importance of NSDS
and set a target of 2002 for the formulation and elaboration of
NSDS that reflect the contributions and responsibilities of all
interested parties.
However, by 2002, based on national reports received from
governments, only about 85 countries had developed some form
of national strategies and the nature and effectiveness of these
strategies varied considerably from country to country. The
Johannesburg Plan of Implementation (JPOI) adopted at the 2002
World Summit on Sustainable Development (WSSD), through
paragraph 162 b, recommitted member States to “take immediate
steps to make progress in the formulation and elaboration of
national strategies for sustainable development and to begin their
implementation by 2005.”
During the preparatory process for the 2002 WSSD, the
International Forum on NSDS was held in Accra, Ghana in 2001,
which led to the launch of the Guidance in Preparing a National
Sustainable Development Strategy. It defined National Sustainable
Development Strategy (NSDS) as “a coordinated, participatory and
iterative process of thoughts and actions to achieve economic,
environmental and social objectives in a balanced and integrative
manner”. Most importantly, NSDS is a call for an institutional
change. It aims at a transition from the traditional static putting-a-
plan-on-paper exercise towards the establishment of an adaptive
system that can continuously improve. It should be a process which
“encompasses situation analysis, formulation of policies and action
plans, implementation, monitoring and regular review. It is a
cyclical and interactive process of planning, participation and
action in which the emphasis is on managing progress towards
sustainability goals rather than producing a ‘plan’ as an end
product.”
Every country needs to determine, for itself, how best to approach
the preparation and implementation of its national sustainable
development strategy depending upon the prevailing political,
historical cultural, ecological circumstances. A "blueprint" approach
for national sustainable development strategies is neither possible
nor desirable. The particular label applied to a national sustainable
development strategy is not important, as long as the underlying
principles characterizing a national sustainable development
strategy are adhered to and that economic, social and
environmental objectives are balanced and integrated.
Today, when incorporating the 2030 Agenda for sustainable
development and its 17 SDGs into national context, although
countries do not necessarily label them as “national sustainable
development strategies”, all the underlying core principles are
deeply embedded in the national implementation of SDGs
worldwide. As seen at the Voluntary National Reviews at the High
Level Political Forum on Sustainable Development, issues such as
country ownership and strong political commitment, the integration
of economic, social and environmental objectives across sectors,
territories and generations; broad participation and effective
partnerships, the development of capacity and enabling
environment, as well as the mobilization of means of
implementations remain at the center of policy debates at all levels.
AGEING, OLDER PERSONS AND THE 2030 AGENDA FOR
SUSTAINABLE DEVELOPMENT
The 2030 Agenda for Sustainable Development sets out a
universal plan of action to achieve sustainable development in a
balanced manner and seeks to realize the human rights of all
people. It calls for leaving no one behind and for ensuring that the
Sustainable Development Goals (SDGs) are met for all segments
of society, at all ages, with a particular focus on the most
vulnerable—including older persons. Preparing for an ageing
population is vital to the achievement of the integrated 2030
Agenda, with ageing cutting across the goals on poverty
eradication, good health, gender equality, economic growth and
decent work, reduced inequalities and sustainable cities.
Therefore, while it is essential to address the exclusion and
vulnerability of—and intersectional discrimination against—many
older persons in the implementation of the new agenda, it is even
more important to go beyond treating older persons as a vulnerable
group. Older persons must be recognized as the active agents of
societal development in order to achieve truly transformative,
inclusive and sustainable development outcomes. The current brief
acknowledges the importance of a life-course approach to ageing
and calls for protecting and promoting the rights of older persons
in the implementation of the 2030 Agenda.
Older persons are important actors in communities, making
key contributions in the following interrelated areas:
1. Economic development: Older persons make substantial
contributions to the economy through participation in the
formal or informal workforce (often beyond retirement age),
taxes and consumption, and transfers of assets and resources
to their families and communities,6 and their broader retention
in the workforce (among those who wish or need to continue
working) has the potential to enhance labour productivity.7
Today more older persons are contributing to an
entrepreneurial ecosystem (Lee 2017), while embracing new
technologies,8 by providing services through digital platforms,
car or accommodation sharing and peer-to-peer lending. In the
contexts affected by absence of breadwinners, migration,
disease outbreaks and conflicts, older persons’ work can be
the only source of monetary or in-kind income to sustain
families.
2. Unpaid care work: Older persons, particularly older women,
play a vital role in providing unpaid care for spouses,
grandchildren and other relatives, including those with
disabilities (UNFPA and HelpAge International 2012).
Furthermore, with changes in family structures, the HIV/AIDS
pandemic and growing migration, grandparents have become
central and indispensable to the well-being of families,9
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 especially in the absence of public care and other social
services
3. Political participation: With variation across contexts, older
persons in some countries, notably in advanced democracies,
can carry significant weight which is mostly associated with the
concentration of economic resources and a tradition of political
participation (UNDESA 2007). As older persons continue to
constitute an ever-greater proportion of the total population,
they have the potential to be more influential in society. This
can have important implications for social, economic and
political outcomes in those countries (progressive but also
regressive), as older persons tend to vote in greater numbers
than young people (Goerres 2009), and are increasingly
forming their own associations such as lobbying groups,
political parties and grassroots organizations (UNFPA and
HelpAge International).
4. Social capital: Many older persons tend to be actively
involved in community and civic life through volunteering,
governance of public institutions, and participation in
community-based institutions. This can contribute to
strengthening social capital in terms of facilitating cooperation
and improving interactions within and between groups based
on shared values, trust and solidarity (OECD 2007). Older
generations are also often the important sources of historical
memory and wisdom, guardians of culture, and repositories of
social traditions and rare knowledge and skills, which can
critically complement those of young people.
Terminologies:
NIH – National Instititutes of Health -the steward of medical and
behavioral research for the Nation. Its mission is to seek
fundamental knowledge about the nature and behavior of living
systems and the application of that knowledge to enhance health,
lengthen life, and reduce illness and disability.
CU13: TRENDS / ISSUES AND CHALLENGES ON THE CARE
OF THE OLDER PERSONS
EDUCATIONAL TRENDS IN GERONTOLOGICAL
Opportunities in gerontological nursing are somewhat correlated
with education level. Many levels of preparation are available for
nurses in gerontology such as:
• Special education in caring for adults during basic preparation
(LPN, RN associate degree, diploma RN, or RN BSN level.
• Post baccalaureate nurses choose a Clinical Nurse Specialist
(CNS) or Geriatric Nurse Practitioner (GNP)
• Online programs for graduate or post-master’s study and
complete clinical hours in their own geographic location
• Certifications in gerontology currently available from the
American Association of Colleges of Nursing (AACN)
• Working in long-term care facilities such as nursing homes,
assisted living, independent living centers, or adult day care,
or in an acute care hospital.
Gerontologic Nurse
The nurse must meet all of the following requirements:
• Currently hold an active
• registered nurse license in US or its territories.
• Hold a baccalaureate or higher degree in nursing.
• Have practiced 2000 hours within past 3 years
• Have had 30 contact hours of continuing education applicable
to gerontology/Gerontologic nursing within the past 3 years.
Gerontologic Nurse Practitioner
The nurse must meet the following requirements:
• Currently hold an active RN license in the US or its territories
• Hold a master’s or higher degree in nursing.
• Have been prepared as a nurse practitioner in either of the
following:
a. A GNP master’s degree in Program
b. A formal postgraduate GNP track or program Within a
school of nursing granting graduate-level academic credit
Clinical Specialist in Gerontologic Nursing
The nurse must meet all the following requirements:
• Currently hold an active RN license in the United States
• or its territories
• Hold a master’s or higher degree in gerontologic nursing
• Hold a master’s or higher degree in nursing with a
specialization in gerontologic nursing.
• Have practiced a minimum of 12 months after completion of
the master’s degree
Meet the following requirements in current practice:
• If a clinical specialist must have provided a minimum of 800
hours (post-master’s) of direct client care or clinical
management in Gerontologic Nursing within the past 24
months
• If a consultant, researcher, educator, or administrator, must
have provided a minimum of 400 hours
Life Care Planning
The concept of life care planning was first developed in the 1980s,
to meet a growing need for an informed document that presented
actual estimated costs of care for persons who had experienced a
catastrophic injury or accident. Many settlements for those persons
in devastating accidents were made arbitrarily without actual
calculation and consideration of the multitudes of factors
influencing these costs, such as doctors’ visits, equipment,
medications, tests, cost of caregiving, and potential complications
over a lifetime. LCP is a comprehensive document designed to
help meet the long-term financial and health needs of a person
experienced catastrophic injury. Life care planners generally
develop plans for insurance companies or lawyers representing
individual clients, but the ultimate goal is to promote the best
outcome for the person for whom the life care plan was written.
The best life care planners have a nearly equal mix between work
for insurance carriers and work for lawyers who present patients,
thus maintaining a neutral and professional reputation for fairness.
Certification
The Certified Life Care Planner (CLCP) designation may be earned
through 128 continuing education hours, successful completion of
a sample life care plan, and passing an examination (MediPro
Seminars, 2004). The CNLCP (Certified Nurse Life Care Planner)
designation is offered by the American Association of Nurse Life
Care Planners Certification Board. It is similar to CLCP, but with
additional requirements, and is definitely designed for registered
nurses with case management experience
Future Potential
Life care planner may be a concept that will be carried into the
senior population. Not only are seniors living longer, but they
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continue participating in higher risk activities today than in
generations past. The principles of life care planning could also
easily be extrapolated for use with those seniors who have long-
term chronic health problems. A good financial planner could
provide a more accurate and detailed projection of health care cost
over a lifetime of disability or illness. The demand for professionals
in gerontology and rehabilitation is likely to grow quickly with the
aging baby boomer group. Gerontological nurses combine their
knowledge in health care with some financial training to offer
distinctive services to the older age group.
Financial Gerontology
Financial gerontology is a growing subfield of financial planning.
FG is defined as “ the intellectual intersection of two fields,
gerontology and finance, each of which has practitioner and
academic components” which combines the knowledge and skills
associated with financial planning and asset management with
expertise in meeting the unique needs of older adults.
Certification for FG
Chartered Advisor for Senior Living (CASL)
✓ A person with CASL certification assists older persons
with retirement savings, pension and social security
planning, health and long-term issues, estate planning and
managing life course transitions, family relationship and
living arrangement.
✓ A person must complete five courses that take
approximately 60-80 hours of study each. After the course
the individual must pass a computerized exam.
Maintenance of the certification with continuing education
credits. A code of ethics must also be agreed to in writing
prior to being granted the designation.
Registered Financial Gerontologist (RFG)
✓ The RFG certifications a similar designation to the CASL,
but is offered through the American Institute of financial
Gerontology and supported by the American Society on
Aging.
✓ The Individual must complete six courses, a learning
requirement, and a comprehensive examination. Course
content is related to wealth span planning, ethics, and
serving the older adult. Compared to CASL courses, the
curriculum appears more suited to gerontologist than
financial planners.
Certified Senior Advisor (CSA)
✓ The CSA is a designation offered by the society of Senior
Advisors. The curriculum includes a large number of topics
in aging, chronic illness, end of life, and long-term care as
well as Medicaid and financial planning.
✓ It is self-study program that takes 2-6 months to complete.
To obtain the CSA, the person must also pass a secured,
computerized, final comprehensive examination online
that consists of 150 multiple choice questions within 3
hours.
Recent trends in health promotion & disease prevention
activities, such as:
• Improved nutrition,
• Decreased smoking,
• Increased exercise, and
• Early detection & treatment of risk factors such as
hypertension & elevated serum cholesterol levels.
TRENDS IN LONG-TERM CARE
Long-term care is the “broad range of medical, custodial, social,
and other care services that assist people who have an impaired
ability to live independently for an extended period”. The National
Council on aging estimates that 6.4 million people all over the age
of 65 and 50% of those over age 85 will need long-term care.
Thirteen million persons in United States currently report having
long-term health needs. This number is expected to grow to 22
million in the next decades. The nation spent $ 183 billion on long-
term care services in 2003 (American Health Care Association &
National Center for Assisted Living, 2005). In 2005, Medicaid spent
nearly $95 billion on long-term care. Persons must pay for many
long-term care expenses from their savings and assets before
being eligible for Medicaid. This has prompted new sources of
funding for future long-term health care needs.
LONG-TERM CARE INSURANCE
Long –term care insurance is designed to cover individuals
needing health care outside of the hospital, including diagnostics
testing, rehabilitation, and custodial care. Reasons for purchasing
long-term care insurance include worrying about being a burden to
their family, staying financially independent, having more choices
for care if needed (such as remaining in the home), preserving their
assets, and providing peace of mind.
The cost of long-term insurance premiums (at age 65) ranges from
$1,000-$2,650 per year, depending upon a number of factors
including health status and history. The average stay in a nursing
home is 2 years. The average cost for a private room in a nursing
home in 2003 was $181.24/day (National Council in aging, 2005).
This average cost increase to $194/day by 2006 (over
$70,000/year), though costs vary widely by geographic area.
Assisted living facilities average $2,691/month for a one-bedroom
unit. Financial analysts predict that if nursing home care costs rise
a bit faster than inflation, by 2026 a room in a nursing home could
cost $ 177,000 per year; another cost projected the cost to increase
to $ 200,000 per year by 2030.
Long-term care insurance can be purchased at any time, but
premiums increase with age. In, 2005, the annual premiums for a
low-option policy for a person who was age 65 was about $1,800,
and increased to about $5,500 at age 79. Long-term care
insurance may cover any one or all of the following types of care.
• Nursing Home care
• Assisted living
• Hospice
• Home health
• Adult day care
• Respite
• Caregiver training
• Home health care coordinators
EMERGING MODELS OF CARE
A Shift to Different Living Facilities
One of most significant changes in care for older adults is the shift
away from nursing homes. As they have known traditionally. Some
predict that the only nursing homes that will survive will be excellent
ones. The institutional look of the older nursing home that was
modeled after the hospital, with long hallways and a sterile-looking
environment, is becoming unacceptable to many older adults as a
place to live out their final days. Newer lonf-term care facilities
4
promote private rooms, residents’ choices and control, and a more
home-like environment that mirrors assisted living facilities of
today.
CONTINUING CARE RETIREMENT COMMUNITIES (CCRCs)
Growing trend for older adults, services by promoting aging in
place through offering various levels of care on a continuum that
might include independent living, assisted living, skilled care, and
home health services all on one campus. The trend will be to bring
services to the CCRCs versus transferring persons to the next level
of care on the continuum (for example, sending them to the
“nursing home” when their care demands increased).
Green Houses
A movement to replace nursing homes with more home-like
environments, started through the vision of a physician named
Bill Thomas, consist of 10-12 residents in a home setting who
enjoy private rooms and share a common living space. This
designed provide a full range of care services, but in a friendly
atmosphere that reminds one of home.
Geriatric Care management
Another emerging trend in gerontological nursing is the role of
the geriatric care manager. The professional geriatric care
manager (PGCM) is a specialist who helps families care for
older adults while encouraging as much independence as
possible. PGCMs may come from a variety of backgrounds
such as social work, psychology. Sociology, geriatrics, and
nursing, nurses have emerged as natural leaders in this
growing field. The educational background knowledge of the
aging process make this role an excellent fit for nurses who
seek a position that affords independence and autonomy while
using their skills
PGCM perform the following:
• Conduct assessments
• Develop care plans that address pertinent problems
• Arrange, interview for, and monitor in-home caregivers or
other services
• Act as a consultant for caregivers who live near or far
• Review financial, health-related, or legal issues
• Provide referrals to other geriatrics specialists
• Intervene in times of crisis
• Act as an advocate and/ or liaison between families and
service providers
• Coordinate or oversee care
• Assist with transitions in living arrangements, including
recommending the most appropriate settings and helping
facilitate the move
• Provide education and links to resources
• Offer counseling and support
• Some PGCMs also offer guardianship, caregiving, and /or
financial services.
COMMUNITY LIVING DESIGNS – another fascinating trend
related to gerontological
Nursing is the emergence of companies completely devoted to the
strategic planning,engineering, architecture, building, and
marketing of community living designs that are tailored to today’s
older adults. Older adults who choose to live in senior communities
expect to have access to transportation and needed services such
as health care, appropriate housing, and opportunities for
socialization. Baby boomers are predicted to live in suburban
communities versus urban or rural areas (Frey 2007), so the need
for age-appropriate and friendly retirement communities is
projected to increase. Lehning,Chun, and Scharlach (2007) stated
that:
An aging –friendly community has three primary characteristics:
1. age is not a significant barrier to the maintenance of life-long
interests and activities;
2. supports and accommodations exist to enable individuals with
age-related disabilities to meet basic health and social needs;
3. opportunities exist for older adults to develop new sources of
fulfillment and engagement.
In spite of the need for such communities, shortfalls in public policy
and lack of creativity in architecture have led to structural barriers
related to best use of land, housing policies, transportation, and
opportunities for involvement in the larger community. There
remains a general lack of concern and investment of suburban
communities in providing housing for the aging portion of their
citizens. This has created a gap in service that potentially can be
filled by forward thinking companies who recognize the plight of
long-term care in this area and stand ready to assist.
One such example of a company developed to assist organizations
with designing and building appropriate and age-friendly living
spaces is Community Living Solutions (2008) of Neenah,
Wisconsin. This company advertises its purpose as “enlightening
your life and community with expert knowledge and sustainable
solutions” . With a unique team of professionals that includes
engineers, architects, and other design experts, companies such
as Community Living Solutions work with organizations such as
continuing care retirement communities (CCRCs), independent
living facilities, and assisted living design and build attractive,
contemporary living areas within a fiscally responsible budget. The
ideal team takes into consideration the mission and needs of the
community and understands the unique limitations and desires of
their older clientele. A great deal of thought and effort goes into
designing an environment that will be attractive and functional for
older adults, and marketable for the institution. Attention to details
such as positioning of garden areas and windows to best use the
space and sunlight is essential, and the savvy builder carefully
plans all aspects of the environment with consideration to older
residents.
Terminologies
Gerontological Nursing - is the specialty of nursing pertaining to
older adults. Gerontological nurses work in collaboration with older
adults, their families, and communities to support healthy aging,
maximum functioning, and quality of life.
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CU14: ADVOCACY PROGRAMS RELEVANT TO THE CARE OF
OLDER PERSONS
ADVOCACY PROGRAMS RELEVANT TO THE CARE OF
OLDER PERSONS
The role of an advocate in health and social care is to
support a vulnerable or disadvantaged person and ensure that their
rights are being upheld in a healthcare context. Health and social
care advocacy means supporting people who are unable to ensure
their best interests are being taken care of. In the medical
profession, activities related to ensuring access to care, navigating
the system, mobilizing resources, addressing health inequities,
influencing health policy and creating system change are known as
health advocacy.
Advocacy services
Advocacy services support the rights of anyone receiving or
seeking to receive aged care services, and empower older people
to make informed decisions about their care. An aged care
advocate can assist things like:
• Interacting with the aged care system
• Transitioning between aged care services
• Knowing and understanding their rights
• Making decisions about the care they receive
• Options for having their aged care needs better met
• Resolving concerns or complaints with the aged care provider
about the services they receive
• Speaking with their service provider at their direction
• Increasing their skills and knowledge to advocate for them self.
Who can access advocacy services?
Anyone who is receiving or seeking to receive government-funded
aged care services, including family and representatives, are
entitled to access advocacy services. This includes people who:
• Live in an aged care home
• Receive aged care services in their own home
• Receive transition care
• Are helping someone who is receiving aged care services.
LEGAL ADVOCACY is a recognized strategy to address social
factors that influence the health of populations with complex care
needs. Such advocacy can improve housing stability, increase
access to public benefits that support a host of social needs,
assure that medical and financial proxy decision makers are in
place, and reduce psychosocial distress.
• Older adults are disproportionately likely to have complex
medical needs. Legal advocacy has been recognized as
integral to the health and health care of older adults in the
medical literature since 1988, and in current Medicare quality
metrics. Additionally, since 1965, the Older Americans Act has
provided legal assistance as an “essential service” among
other aging supports such as nutrition, transportation, and in-
home care. Under the act, state area agencies on aging must
provide legal services free to adults older than age 60 with the
“greatest social or economic need.”
• Yet, while emerging care models for older adults with complex
needs are highly multidisciplinary, none incorporate legal
advocacy in their design. This is in some ways not surprising
as clinicians are not trained to recognize or address legal
needs of older patients, and older patients are unable to self-
diagnose their legal problems, thus making it unlikely that they
will articulate legal needs as such to health care providers,
social workers, or case managers.
• In addition, funding mechanisms for health care and social
services—especially civil legal services—are highly soloed
and deeply asymmetrical. Historical underinvestment in civil
legal services for the poor has led to a shortfall in the legal
workforce serving this population. This may provide another
explanation for why legal advocacy has not been particularly
visible to health systems: Legal advocates are focused on
emergency legal needs such as loss of housing, neglect and
exploitation, and loss of public benefits. Although these needs
could be better served through preventive and primary legal
advocacy delivered holistically in coordination with other social
services and health care, funding levels have not enabled
such an approach.
HEALTHY PEOPLE INITIATIVES
The federal government has been establishing goals for
healthy aging since 1980 when the U.S. Public Health Service
published the report Promoting Health/ Preventing Disease
Objectives for the Nation. This 1980 report outlined 226 objectives
for the nation to achieve over the following 10 years. It was referred
to by some as Healthy People 1990.
A decade later, in 1990, another10-year national effort,
Healthy People 2000, was initiated by the U.S. Public Health
Service in another effort to reduce preventable death and disability
for Americans. A third effort is currently under way with the Healthy
People 2010 initiative; however the number objectives has
increased to 467, and these are distributed over 28 priority areas.
There are some notable benefits to the healthy people
initiatives. On the positive side, these initiatives give recognition to
health promotion rather than focusing exclusively on wars on
disease (e.g. tabulating the number of deaths from cancer or heart
disease, and then organizing a campaign against them). The
Healthy People initiatives are health oriented, and as such they
recognize the complexity of the socioeconomic, lifestyle, and other
nonmedical influences that impact our ability to attain and maintain
health.
Healthy People 2020
Healthy People 2020 was the fourth iteration of the Healthy People
initiative. Launched in December 2010, Healthy People 2020 set
an ambitious yet achievable 10-year agenda for improving the
nation’s health.
The vision for Healthy People 2020 was “a society in which all
people live long, healthy lives.”
Its mission was to:
• Identify nationwide health improvement priorities
• Increase public awareness and understanding of the
determinants of health, disease, and disability and the
opportunities for progress
• Provide measurable objectives and goals that are applicable
at the national, state, and local levels
• Engage multiple sectors to take actions to strengthen policies
and improve practices that are driven by the best available
evidence and knowledge
• Identify critical research, evaluation, and data collection needs
6
Healthy People 2020 set overarching goals to:
• Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death
• Achieve health equity, eliminate disparities, and improve the
health of all groups
• Create social and physical environments that promote good
health for all
• Promote quality of life, healthy development, and healthy
behaviors across all life stages
Healthy People 2020 Law and Health Policy
The Healthy People 2020 Law and Health Policy project aimed to
raise awareness of the impact that legal or policy interventions can
have on public health. The project was a partnership
between ODPHP, CDC, the CDC Foundation, and the Robert
Wood Johnson Foundation.
These organizations worked with subject matter experts and
federal stakeholders to create reports, webinars, and products to
highlight laws and policies with the potential to impact specific
Healthy People 2020 topic areas and objectives.
Advancing Public Health Through Law and Policy
Law and policy are among the most effective tools to improve
health. Many of the greatest public health successes in the United
States are the result of legal or policy interventions, such as smoke-
free air laws and mandatory seatbelt laws.1 Yet many people may
not be aware of the precise impact these interventions and
approaches can have on population health.
Law and Health Policy Resources
Project partners worked with subject matter experts and federal
stakeholders to develop a series of Healthy People 2020 topic-
specific reports, webinars, and other evidence-based products
such as infographics and success stories, or Bright Spots. These
resources and publications highlight laws and policies with the
potential to impact specific Healthy People 2020 topic areas and
objectives, including Leading Health Indicators.
Review different resources produced by the Law and Health
Policy project:
• Disability and Health
• Healthcare-Associated Infections
• Health Equity
• Healthy People 2030
• Leading Health Indicators
• Maternal, Infant, and Child Health
• Mental Health and Mental Disorders
• Nutrition and Weight Status
• Oral Health
• Policy Levers
• Substance Abuse
MODEL HEALTH PROMOTION PROGRAMS FOR OLDER
ADULTS
One of the more recent efforts in this regard has been
organized by the Health Promotion Institute (HPI) of the National
Council in Aging. HPI started by summarizing 16 model programs
or best practices and compiling them into a loose-leaf directory.
The summarizes included information on the planning process,
implementation of the program, and program evaluations.
Six model health promotion programs that have been
focused on older adults and have received national attention,
received federal funding and foundation support to evaluate their
effectiveness and to encourage their replication.
1. Healthwise
The best-known older adult medical self-care program is
Healthwise. It provides information and prevention tips on 190
common health problems, with information periodically updated.
The Healthwise Handbook (Healthwise,2006)is now in its 17 th
edition. This handbook includes physician-approved guidelines on
when to call a health professional for each of the health problems
its cover.
With the assistance of a $2.1 million grant from Robert Wood
Johnson Foundation, Healthwise distributed its medical self-care
guide to 125,000 Idaho households, along with toll free nurse
consultation phone service and self-care workshops. Thirty-nine
percent of handbook recipients reported that the handbook helped
them avoid a visit to the doctor. Blue Cross of Idaho reported 18%
fewer visits to the emergency room by owners of the guide.
2. Chronic Disease Management
Kate Lorig, a nurse-researcher at the Standford University
School of Medicine, and her medical colleagues have been
evaluating community-based, peer-led,chronic disease self-
management programs for more than two decades, beginning with
the Arthritis Self-Management Program (Lorig et ai.,1986) This
program has since evolved into a curriculum that is applicable to a
wide array of chronic diseases and conditions.
Typically, each program involves about a dozen participants,
led by per leaders who have received 20 hours of training. The peer
leaders, like the students, are typically older and have chronic
diseases that they contend with. The program consists of six
weekly sessions about 2 ½ hours long each, with a content focus
on exercise, symptom management, nutrition, fatigue and sleep
management, use of medications, managing emotions, community
resources, communicating with health professionals, problem
solving, and decision making. The program takes place in
community settings such as seniors centers, churches, and
hospitals.
The theoretical basis of the program has been to promote a
sense of personal efficacy among participants by using such
techniques as guided mastery of skills, peer modeling,
reinterpretation of symptoms, social persuasion through group
support, and individual self-management guidance.
3. Project Enhance
Senior Services of Seattle/King County began the Senior
Wellness Project (later renamed Project Enhance) in 1997 at the
North Shore Senior Center in Bothell, Washington. It was a
research-based health promotion program that included a
component of chronic care self-management that was modeled
after Kate Lorig’s program (Lorig et al.,1999) The program also
included health and functional assessments; individual and group
counseling; exercise programs; a personal health action plan with
the support of a nurse, social worker, and volunteer health mentor;
and support groups. A randomized controlled study of chronically
ill seniors reported a reduction in a number of hospitals stays and
7
average length of stay, a reduction in psychotropic medications,
and better functioning in activities of daily living.
4. Ornish Program for Reversing Heart Disease
Dr. Dean Ornish, a physician at the University of California at
San Francisco and founder of the Preventive Medicine Research
Institute, has developed a program for reversing heart disease that
has been replicated at several sites around the country. Dr. Ornish
(1992) has recommended a vegetarian diet with fat intake of 10%
or less of total calories, moderate aerobic exercise at least three
times a week, yoga and meditation an hour a day, group support
sessions, and smoking cessation.
Dr. Ornish and his colleagues have reported that as a result of
their program, blockages in arteries have decreased in size, and
blood flow has improved in as many as 82% of their heart patients
(Gould et al.,1995). A five-year follow-up of this program reported
an 8% reduction in atherosclerotic plaques, while the control group
had a 28% increase.
5. Benson’s Mind / Body Medical Institute
Dr. Herbert Benson is a physician affiliated with Harvard
Medical School, and best known for his best-selling books on the
relaxation response and for popularizing the term mind/body
medicine. For individuals feeling the negative effects of stress,
Benson’s program teaches them to elicit the relaxation response,
a western version of meditation. The Benson-Henry Institute for
Mind/Body Medicine’s clinical programs treat patients with a
combination response techniques, proper nutrition and exercise,
and the reframing of negative thinking patterns.
6. Strong for Life
The Strong for Life Program is a home-based exercise
program for disabled and nondisabled older adults. It focuses on
strength and balance, and provides an exercise video, a trainer’s
manual, and a user’s guide. The program was designed by
physical therapists for home use by older adults, and relies on
elastic resistive bands for strengthening muscles. The exercise
program led to high rate of exercise adherence among older
participants, as well as increased lower extremity strength,
improvements in tandem gait, and a reduction in physical disability
(Jette et al., 1999)
Terminologies:
Advocacy - public support for or recommendation of a particular
cause or policy. "their advocacy of traditional family values"
CU15: TELEHEALTH AND THE OLDER PERSON
Telehealth allows patients across the lifespan to receive care
remotely in a manner that is often more accessible and convenient
than in-person care. A common misconception is that older adults
have either no interest in the use of technology or cannot use
technology platforms. Current data indicate otherwise; in fact, most
older adults (7 in 10) have and utilize a computer, smart phone, or
tablet with internet access at home. However, when it comes to the
use of telehealth, there is limited reach among older adults (e.g.,
only 11% feel comfortable using telehealth).
Beyond reimbursement limitations with health insurance,
barriers to telehealth among older adults include provider
misperceptions of interest, lack of telehealth training/orientation in
older adults, and telehealth platforms that do not account for the
needs of older adults.
Here are some factors to consider and strategies to implement
when providing telehealth to older adults.
A. SENSORY AND MOTOR CHANGES
• Most older adults experience age-related changes in vision,
hearing, touch, perception, mobility, and balance. Many of
these declines begin at age 40.
• For older adults, there may be difficulties with light perception,
sensitivity to glare, reduced acuity, and impaired focus on
nearby objects.
• Discriminating between background noises becomes more
difficult as we age, and low-level sounds are muffled. And for
some, there is increased risk of developing Tinnitus, which can
make certain sounds difficult to discern.
• There are also changes to muscle strength and tone that make
muscles stiffer and less
B. COGNITIVE CHANGES
• Most older adults experience some cognitive changes as a
part of the normal aging process, such as slowed speed of
processing, difficulty in multitasking, and small declines in
episodic memory, which generally do not interfere with
everyday functioning. However, many cognitive abilities,
including semantic memory, reasoning, problem solving, and
executive functioning are preserved well into late life. The
relatively minor cognitive changes that occur with aging should
not prevent use of telehealth by older adults.
• Even adults who experience conditions such as mild cognitive
impairment (MCI) can successfully learn new skills, especially
if they use compensatory strategies like making notes or using
reminders. This could include making reminders about
telehealth appointment times in their calendar and using a
series of written notes about how to start their computer or
tablet and launch a telehealth application.
• There are some older adults whose cognitive impairments
may be too advanced to use telehealth successfully (for
instance, in severe dementia). However, some older adults
with mild forms of dementia can use telehealth effectively with
some modifications or adjustments. For instance, they may
need a family member’s assistance to set up the telehealth
account or to get the telehealth session started.
C. STRATEGIES FOR PROVIDING TECHNOLOGY SUPPORT
• Don’t assume older adults are uninterested in telehealth.
• Just as you do with all patients, meet older adults where they
are and talk about the pros and cons of telehealth. Provide a
clear explanation of what to expect and let them know that
most people experience a few “bumps” adjusting to new
technology but you’ve been able to successfully work with
people with this modality.
• Providing technology support requires additional resources
early in treatment but avoids delays on the day of the
appointment, so plan to provide additional instruction and
individual tech support. Though telehealth platforms may not
be intuitive to older adults, many can successfully use them.
Contact the older adult over the telephone prior to the
appointment to provide verbal instructions, test the telehealth
platform, and ensure the older adult understands and is
8
 comfortable with the technology. Support staff may be able to
do this step. Additional benefits include increasing older
adults’ access to care and promoting treatment continuity by
overcoming barriers to in-person sessions.
• Prior to the appointment, provide older adults with written
instructions for using telehealth (you may find this beneficial
for all your patients). Instructions that use concise language, a
larger font size, and include screen shots of each step of the
process may be particularly helpful.
• Older adults using telehealth technology will benefit from
visual presentation modifications (e.g., raise display/screen
illumination, use matte surfaces instead of glossy surfaces).
• Auditory enhancements may also help the user experience
(e.g., adjust volume settings, offer closed captioning options
with enhanced text size, consider the use of headphone sets).
• You can provide these suggestions in the initial written
information or discuss during the setting up session.
• When using a video platform, a neutral, not “busy” visual
background for you will ensure the older adult with visual
challenges is better able to focus on you and not other stimuli
in the background. Similarly, reducing noise on the provider’s
end reduces auditory interference for the patient. Be aware of
noises such as HVAC, white noise generators, and other
sounds and seek to minimize these with the position of your
equipment and the use of headphones.
• To curb pain from muscle stiffness, ask your patient if they
need movement accommodations for their sessions (e.g.,
allow time for stretching, invite older adults to use items that
may be of comfort like heating pads, comfortable chairs, etc.).
• Providing an end-of-session summary of the goals, reading,
and exercises to be completed between sessions can be
advantageous for all clients but especially valuable for older
adults.
D. STRATEGIES FOR ESTABLISHING RAPPORT
• Directly acknowledge that telehealth sessions can feel
awkward. Reassure older adults that most people feel
increasingly comfortable over time.
• Attempt to look directly at the camera as much as possible to
mimic eye contact.
• Use clarifying and reflective techniques to avoid
miscommunication and misinterpretation of the older adult’s
emotions. Clarify ambiguous body language verbally with the
acknowledgement that telehealth can make communication
more difficult (e.g., “I want to make sure I understand how you
are feeling. Meeting over video can make that more difficult
since I can’t see you completely. You seem to be frustrated—
is that how you are feeling?”).
• Implementing these strategies could increase the likelihood of
older adults successfully engaging in and benefiting from
telehealth.
Using Telehealth to Care for the Elderly
When we think of digital technology, we tend to think of
younger individuals using their smartphones and other digital
devices. But this line of thinking doesn’t necessarily apply to
telehealth. Older generations can use telehealth technology to
improve their access to care and reduce the cost of healthcare
services.
The number of Americans age 65 and older is rising
dramatically. Estimates show this demographic will rise from 46
million today to 98 million by the year 2060. With more elderly
patients seeking care, families will have to make difficult decisions
when figuring out how to best care for their loved one.
The cost of a nursing home can be out of reach for many
Americans, which means many families will need to stay at home
to care for their loved one. Telehealth can reduce the burden on
these families by lowering the cost of essential healthcare services.
Learn more about how geriatric patients and their families can
benefit from telehealth.
The Need for Affordable Elderly Care
Elderly patients tend to have complex healthcare needs as they
manage a range of conditions and diseases. But getting access to
healthcare can be a challenge for many elderly patients, especially
for those that live in rural areas. Around 7 million older adults are
considered homebound or have trouble leaving their home without
help.
Without a loved one to help them or a dedicated driver, these
individuals may be unable to visit their healthcare provider in
person, leaving them with few alternatives unless they have access
to telehealth services.
The price of putting an older patient in a nursing home is simply
unaffordable for many families. Additionally, older patients tend to
prefer at-home care to staying in a nursing home. In many cases,
a loved one will move in with the older patient to provide at-home
care, but, without proper training, many of these family caregivers
will still need the advice and support of the healthcare community.
How Telehealth Can Improve Access to Elderly Care
Telehealth gives patients the option to consult with their healthcare
provider remotely using live video, audio and instant messaging on
a telemedicine app. This reduces the need for in-person visits and
consultations, making it easier for at-home caregivers to meet the
needs of their loved ones.
Many of these at-home caregivers will have responsibilities of their
own, from raising children to holding down a job. If they can consult
with their loved one’s doctor from the comfort of their own home,
they won’t have to spend as much time shuttling their loved one to
and from the doctor’s office. At-home healthcare providers can
quickly gain valuable insight and knowledge from these remote
consultations, improving their loved one’s quality of care.
Telehealth can help families and elderly patients in the
following ways:
• Reduce the burden and cost of certain travel expenses
• Reduce the number of unnecessary hospital visits
• Reduce the stress put on at-home caregivers
• Improve overall patient satisfaction
Using Telehealth to Care for the Elderly
At-home caregivers can use telehealth to help better manage and
treat a range of conditions and diseases that tend to affect older
patients. While in many of these cases, in-person visits will still be
required, telehealth makes it easier for family caregivers to care for
their loved one by giving them direct access to healthcare
professionals. If they have a question about caring for their loved
one, they can always consult with a licensed physician or specialist
using telemedicine video conferencing software.
Telehealth can be used to care for and manage the following
conditions and diseases:
9
 Palliative Care
At-home caregivers can use telehealth to report on the
condition of their loved one as their health continues to
deteriorate while receiving valuable feedback and advice
from healthcare professionals.
Transitional Care for Heart Failure
At-home caregivers can use telehealth to stay on top of their
loved one’s treatment regimen following an episode of heart
failure, including dispensing medications, diet, physical
activity, and managing stress levels.
Chronic Disease Management
Telehealth helps at-home caregivers report on the condition
of their loved one, giving healthcare providers insight into how
their disease is progressing over time. Caregivers can use
telehealth to stay on top of medications, dietary information,
and mental and physical changes.
Primary Care for Frail Individuals
Patients that have trouble moving or leaving the house can
use telehealth to consult with healthcare professionals on a
variety of primary healthcare issues and concerns, including
joint pain, muscle stiffness, medications, and accident
management and prevention.
There are so many ways elderly patients and family caregivers can
use telehealth to their advantage. Digital healthcare services
reduce the need for in-person appointments, lower the cost of care,
reduce costly visits to the emergency room, and improve patient
satisfaction. As more patients reach the age of retirement, more
families will need to depend on these services to care for their
elderly loved one.
Benefits and Limitations
As the COVID-19 pandemic continues, depression and anxiety are
on the rise. As a result, mental healthcare providers are being
pushed to provide care to more patients, while keeping
themselves, their staff, and patients safe.
Many are turning to telehealth as a way to provide treatment to
patients when they can’t be seen in person. The integration
of telehealth into traditional medicine could reach far beyond the
pandemic and into the future.
Telehealth does have its positives and negatives, though. When
implementing a plan for seniors and telehealth, healthcare
providers should consider both the barriers and opportunities to
conduct the most effective telehealth visits for their patients and
themselves.
Are Mental Telehealth Visits as Effective as In-Office Mental
Health Visits?
Yes, they can be. According to an article published in Annual
Review of Clinical Psychiatry, evidence from more than 100
controlled trials suggests that guided Internet treatments for a wide
range of psychiatric and somatic conditions “can be as effective as
face-to-face treatments, lead to sustained improvements, work in
clinically representative conditions, and probably are cost-
effective.”
The Commonwealth Fund concurs in its To the Point blog post,
stating “numerous studies have demonstrated [telehealth’s]
effectiveness across a range of modalities (e.g., telephone,
videoconference) and mental health concerns (e.g., depression,
substance use disorders). Virtual services are safe, effective and
comparable in outcomes to in-person services.”
Mental Healthcare Providers, Older Adults, and Telehealth
Usage
The American Academy of Family Physicians (AAFP) defines
telehealth as “electronic and telecommunications technologies and
services used to provide care and services at-a-
distance.” Telepsychiatry is a specific form of telehealth that,
according to the American Psychiatric Association (APA), “can
involve direct interaction between a psychiatrist and the patient”
and include “psychiatrists supporting primary care providers with
mental health care consultation and expertise.”
“Video-based telepsychiatry helps meet patients’ needs for
convenient, affordable, and readily accessible mental health
services,” according to the APA.
According to the 2020 Survey of America’s Physicians, conducted
by Merritt Hawkins in collaboration with The Physicians
Foundation, 48 percent of U.S. physicians currently are treating
patients through telemedicine compared to only 18 percent in
2018.
Meanwhile, 26 percent of people 50 to 80 years old reported having
had a virtual medical visit since the outbreak of COVID-19,
according to the University of Michigan (U of M) 2020 National Poll
on Healthy Aging (NPHA). This is compared to only four percent in
the 2019 NPHA.
Why is Mental Telehealth Important for Older Patients?
There are multiple, potential benefits for older adults who use
telehealth to communicate with their mental health practitioners.
At the top of the list is access, according to the APA. During the
pandemic, access is vital, especially since some seniors may be
immunocompromised. Additionally, bringing care to the patient’s
home or location via telehealth may open possibilities for those
who live in remote or rural areas to connect more easily with mental
healthcare specialists.
The APA suggests several other benefits of telehealth including:
• “Help integrate behavioral health care and primary
• are, leading to better outcomes
• Reduce the need for trips to the emergency room
• Reduce delays in care
• Improve continuity of care and follow-up
• Reduce the need for time off work, childcare services, etc. to
access appointments far away
• Reduce potential transportation barriers, such as lack of
transportation or the need for long drives
• Reduce the barrier of stigma”
Telehealth becomes especially important as more older adults are
suffering from mental disorders at a time when their ability to meet
with healthcare providers in person has decreased significantly.
Statistics from the American Association for Geriatric
Psychiatry show that 20 percent of adults age 55 and older have a
mental health disorder such as anxiety, cognitive impairment, or
mood disorder. More recent data from the Centers for Disease
Control and Prevention (CDC), gathered between April and August
2020, show that week by week, the number of adults aged 50 to 59
who reported suffering from either depression or anxiety has risen
10
to levels as high as 40 percent. Additionally, those in the 60 to 69
age range showed highs of 32%, while those in the 70 to 79 or the
80 years and above age ranges showed highs near 25%.
Geriatrician Laurence M. Solberg, MD, who has been using
telemedicine through the U.S. Department of Veterans Affairs (VA)
for more than a decade, writes in the Institute for the Healthcare
Improvement blog that “televisits are especially good for frail, older
people because they don’t get worn out from the traveling to your
office.”
Solberg recognizes that in spite of the benefits, there are
communication challenges that practitioners may need to manage
when using telehealth with older patients. Particularly, some
providers may find it hard to make sure that communication with
older adults over an audio line or video screen does not seem
impersonal or give the impression that the provider is “just going
through the motions.”
To overcome these obstacles, he recommends that providers
consider using the 4Ms Framework:
• Address what MATTERS to the patient in terms of their goals,
preferences and priorities
• What MEDICATIONS they currently take
• Their level of cognitive impairment or MENTATION
• Their level of MOBILITY
• “Using the 4Ms Framework is a simple way to personalize
telemedicine and make it more supportive of older patients,”
Solberg writes.
• How to Make Telehealth Easier for Older Patients
CU16: ENTREPRENEURIAL OPPORTUNITIES
NURSE ENTREPRENEUR
Nurse entrepreneurs use their professional nursing
experience and education to start their own business in the
healthcare industry. Businesses established by nurse
entrepreneurs may include developing and selling a home health
product or medical device, or offering independent nursing
services, such as patient care, nursing education, home health
and/or consulting services. A nursing career path that offers
independence and autonomy, becoming a nurse entrepreneur
requires creativity, hard work and strong business skills.
As in other nursing careers, aspiring nurse entrepreneurs
begin their careers by completing their Associate's Degree in
Nursing or Bachelor of Science in Nursing degree and pass
the NCLEX-RN exam. In addition to the standard nursing
education, nurse entrepreneurs benefit significantly from learning
important business skills such as marketing, accounting and
managerial techniques. Then an aspiring nurse entrepreneur often
begins work as a professional nurse in order to learn the industry
and discover business opportunities within it.
While an advanced degree is not required for nurse
entrepreneurs to start their own business, many nurses may
consider a dual master's degree program in nursing and business
administration, in which students complete their Master's of
Science in Nursing and Master of Business Administration degrees
simultaneously.
Nurse entrepreneurs work for themselves and therefore
the skills required for this position vary depending on the nature of
the individual business venture, but in general the following skills
and qualifications are beneficial for nurse entrepreneurs:
• ADN (Associate Degree in Nursing) or BSN degree and valid
RN license
• Prior professional nursing experience within the relevant area
of specialty
• Basic business skills and knowledge (e.g., accounting,
marketing, ability to manage staff)
• Good communication skills for interacting with customers,
patients and employees
• Ability to work independently and willingness to take on
personal financial risk
In general, nurse entrepreneurs have completed a minimum
of the ADN or BSN degree and have attained an RN license in the
state in which they live. A background in business is also highly
valuable for nurses who wish to start their own businesses. This
may include informal training or mentoring in business skills, taking
a few courses in business, or attaining a business degree. Many
nursing schools across the country offer dual programs which
deliver MSN and MBA degrees simultaneously.
Certifications or Credentials Needed?
There are no specific certifications or credentials required
for becoming a nurse entrepreneur. However, a nurse
entrepreneur may find certain certifications valuable based on the
nature of their business. For instance, a nurse who runs a home
health company and provides patient care may wish to hold
the Basic Life Support Certification (BLS) from the American Heart
Association or American Red Cross.
Nurse entrepreneurs may work in a variety of settings,
including in offices running their own business, as an independent
nurse contractor in hospitals or clinics, in home healthcare visiting
patients, or as a nurse educator. Nurse entrepreneurs have the
freedom to set their own hours and the flexibility to determine their
own work environments based on the company they establish.
Nurse Entrepreneur Do
A nurse entrepreneur uses his or her background in
professional nursing to start their own business within the
healthcare industry. Business ventures established by registered
nurses run the gamut from medical devices and home health
products to independent nursing services such as patient care,
nursing education, home health services and consulting work. The
day-to-day responsibilities of a nurse entrepreneur depends upon
the specific venture, but usually includes activities related to
running a business including accounting, marketing or sales, and
developing a customer base.
Roles and Duties of a Nurse Entrepreneur
• Use nursing education and experience to establish their own
business venture within the healthcare field
• Promote the business, including advertising and sales efforts
to attract and retain customers
• Hire and manage employees to assist in running the business
as needed
• Tend to the financial side of running a business, including
accounting, payroll and tax issues
• Provide healthcare products or nursing services which may
include direct patient care, education or consulting services
depending on the nature of the business
11
Nurse Entrepreneurial

An increasing number of nurses are enjoying the benefits

of self-employment. While salary can vary widely based on the
specifics of their business ventures, many nurse entrepreneurs are
also independent nurse contractors who set the terms of their own
services and negotiate their salary with a healthcare facility, such
as a hospital or nursing home. While not as certain as traditional
employment, a career as a nurse entrepreneur can be more
profitable than a standard RN position.

Terminologies:

NURSE ENTREPRENEUR - defined as “a proprietor of a business

that offers nursing services of a direct care, educational, research,
administrative, or consultative nature”.

12
WEEK 13: MUSCULOSKELETAL SYSTEM • Back pain due to compression
• Loss of height
Age Related Changes in Structure and Function
• Kyphosis – excessive curvature of spine
• Disease of the musculoskeletal system are usually not fatal • Fracture with minor trauma
but may lead to chronic pain and disability Treatment
• Impairments in the ability to perform activities of daily living
a. Bathing • Encourage adequate exercise and nutrition
b. Dressing a. Vitamin D – helps in absorption in calcium Sunlight,
c. Eating green leafy vegetables
b. Calcium – cheese, oranges, Milk
Common problems and conditions of the musculoskeletal c. Exercise
system • Calcium supplementation
• Fractures are common problems for older adults that often • Administer bisphosphate
result in some loss of functional ability. (bone brittleness) a. Inhibits osteoclastic resorption and bone density
(process of body to breakdown the bone in order to build
• Fracture is a break or disruption in the continuity of the bone
up); 48-72 hours
Fractures b. Alendronate
If a fracture is suspected, assess injured area of the c. Risedronate
following: d. Ibandronate sodium
• Administer calcitonin nasal spray – It can increase bone
• Pain density and analgesic effect for bone pain (2-4 weeks intake)
• Pallor – cyanosis • Administer selective estrogen receptor modulator
• Pulse – pulselessness; no pulse (problem in nerves a. Decrease in estrogen
circulation or tissue perfusion b. Menopausal women
• Poikilothermia – inability to regulate body temperature c. For prevention of osteoporosis
secondary to constriction d. Raloxifene
• Paresthesia – tingling sensation • Administer Teriparatides – stimulates of production of
• Paralysis – decrease function of that extremity that can lead collagen to increase bone density
to amputation (surgical removal applicable only to • Administer Vitamin D
extremities)
OSTEOARTHRITIS
If fracture is open and bleeding is present
• Degenerative joint disease caused by wear and tear of the
• Apply pressure articular cartilage
• Apply sterile dressing
• Immobilize the fracture site Pathophysiology
a. Spinal cord fracture – don’t move the patient, put neck
Worn joint cartilage
brace to avoid quadriplegia (paralysis of both upper and Underlying bones become exposed
lower extremities); Rubbing of bones
b. thoracic cavity – paraplegia (paralysis of both lower Degenerative changes in bones
extremities) Causes jagged joint spaces and bone spurs
Projects into soft tissue or joint spaces
Pain
Age-Related Disease And Injury Of The Bone

OSTEOPOROSIS Signs and symptoms

• a condition in which the bones become brittle and fragile from • Stiff joints for short time in morning (15 mins)
loss of tissue, typically as a result of the hormonal changes, • Joint pain with movement or weight
or deficiency of calcium or vitamin D • Crepitus – rubbing and grating feeling of joint
• Pain relief when joints are rested
Pathophysiology • Enlargement of joint
• Heberden’s nodes – enlargement of joints (distal or tip of the
Decrease in bone density (decrease
production of estrogen) fingers); proximal or middle fingers – Bouchard’s nodes
Bones become brittle Treatment
Risk of fracture
Bone-building activity does not keep up with • Administer NSAID (nonsteroidal anti-inflammatory drug) –
bone-resorption activity administer full stomach
Structural integrity is compromised • Administer acetaminophen for pain relief
Osteoporosis a. Ibuprofen
b. Diclofenac sodium
Signs and symptoms c. Naproxen
• Asymptomatic d. Ketorolac

13
• Glucosamine and chondroitin sulfate – relieve pain and ✓ Muscle weakness
stiffness of the joints ✓ Hypocalcemia
• Intra-articular injections of corticosteroids up to 3-4 times in a ✓ Compressed vertebrae
year ✓ Pelvic flattening
a. no prolonged intake of corticosteroid for diabetic patient ✓ Fractures
✓ Easy fracturing
because it can increase glucose
✓ Bone softening
• Exercise to maintain joint mobility and muscle tone ✓ Bending of the bones
• Walking aid for stability ✓ Pain
✓ Bone fractures
RHEUMATOID ARTHRITIS
Tx ✓ Nutritional osteomalacia responds well to
administration of 10,000 IU (international unit)
• Is a systematic inflammatory disease mainly characterized by
weekly of vitamin D for four to six weeks
synovitis and joint destruction
✓ Osteomalacia due to malabsorption may require
• Etiology is unknown but genetic is of the basis. treatment by injection or daily oral dosing of
significant amounts of vitamin D.
Assessment and Diagnostics

• Elevated Erythrocyte Sedimentation rate (ESR) – hallmark of PAGET’S DISEASE

inflammation
• Paget’s disease of the bone (other terms are Paget’s
Medical Management disease, osteitis deformans, osteodystrophia deformans) is a
chronic disorder that typically results in enlarged and
• NSAIDS deformed bones.
• Cyclo-oxygenase 2 (COX-2) blockers (Celecoxib)
a. Decrease risk of gastric irritation and ulceration S/Sx ✓ Bone pain is the most common symptom
b. Can take with empty stomach ✓ Headaches and hearing loss
✓ Pressure on nerves
• Gold coumpounds (chrysotherapy) – myocrisin
✓ Somnolence (drowsiness)
a. 4-6 months before taking
✓ Paralysis
b. DMARD – Disease Modifying Anti-Rheumatic Drugs ✓ Curvature of spine
- Joint pain, stiffness, swelling, can reduce bone ✓ Hip pain
damage and joint deformity and disability ✓ Arthritis
c. Sodium aurothiomalate ✓ Teeth may spread intraorally
d. Glucocorticoids ✓ Chalkstick fractures can occur
e. Side effects: Can cause mouth ulcer, white spots on the
lips and throat, skin pigmentation due to prolonged Tx ✓ Biphosphates
treatment, diarrhea, stomach pain and cramps and a. Taken with empty stomach
indigestion b. With 200-250 ml or 6-8 cup of water (tap
• Corticosteroids water; NOT mineral water – not effective)
c. Contraindicated with kidney failure px
Clinical Manifestation ✓ Calcitonin
✓ Surgery
• Joint pain ✓ Diet and exercise
a. Pattern (bilateral/symmetric)
1. Both shoulders GOUT
2. Both elbows
3. Both hips • Metabolic disorder in which the body does not properly
4. Both Knees metabolize purine-based proteins – increased amount of uric
b. Joint stiffness in the morning NOT relieved by moving acid (end product of purine metabolism) – uric acid crystals
• Swelling and warmth accumulate in joints – joint pain
• Erythema • Don’t eat foods that contains purine – sardines, anchovy,
• Rheumatoid nodules scallops
a. Heberden’s nodes – tips of finger • Uric acid is cleared by the kidney – stones and uric acid
b. Bouchard’s nodes – bumps in the middle joint of fingers crystals in the kidney
• PANNUS formation – hardening of synovium (sac filled Signs and symptoms
synovial fluid that is responsible for lubrication of joints) ✓ Acute onset of excruciating pain in joint due to
accumulation of uric acid within the joint
OSTEOMALACIA
✓ Redness due to inflammation around the joint
• Softening of the bones due to defective bone mineralization ✓ Nephrolithiasis (kidney stones) due to uric acid deposits in
the kidney
• Not enough vitamin D in the diet
Treatment
• Not enough exposure to sunlight, which produces vitamin D
✓ Administer Colchicine during and acute episode – anti-
in the body inflammatory drug, decrease inflammatory response
• Malabsorption of vitamin D by the intestine secondary to uric acid deposits and pain
✓ NSAIDs to decrease inflammation
S/SX ✓ Weak bones a. Not aspirin – regular dosing causes retention of uric
✓ Bone pain acid, it can severe the disease of the patient

14
 ✓ Xanthine oxidase inhibitor medication – reduce total body • Contagious-focus osteomyelitis – from contamination from
uric acid, long term medication bone surgery, open fracture, or traumatic injury
✓ Administer uricosuric medication • Osteomyelitis with vascular insufficiency diabetic patients,
✓ Low-fat, low-cholesterol diet – elevated uric acid levels peripheral vascular disease
accelerated atherosclerosis
✓ Immobilize the joint for comfort Clinical manifestation
Nursing interventions
✓ Have the patient drink 3 liters of fluid per day • Signs and symptoms of Sepsis
✓ Monitor uric acid levels in serum • Pain on the affected bone (constant pulsating
✓ Assist with positioning for comfort
✓ Avoid touching inflamed join unnecessarily Assessment and diagnosis
✓ Explain to patient food NOT TO EAT
a. Which foods are high-purine proteins – turkey, organ • X-ray (soft tissue edema)
meats, sardines, smelts, mackerel, anchovies, • MRI (early definitive diagnosis)
herring, bacon • Elevated ESR
b. Avoid alcohol, which inhibits renal excretion of uric • Positive blood culture
acid
WEEK 14: GASTROINTESTINAL SYSTEM
HIP FRACTURE
AGING IN THE GI
• A hip fracture is a fracture in the proximal end of the femur
near the jip joint Most affected by age: age related changes
• Often due to osteoporosis; a hip fracture is a fragility fracture
a. Upper tract – pharynx & esophagus
due to fall or minor trauma in someone with weakened
b. Colon
osteoporotic bone
• Most hip fractures in people with normal bone are the result THE MOUTH
of high-energy trauma such as car accidents
• Changes in the ability to chew
Treatment • Dental decay and tooth loss
• There is atrophy of muscles and bones of the jaw: difficulty
• Most hip fractures are treated by orthopedic surgery, which
in chewing
involves implanting an orthosis
• Salivary gland function remains the stable with age
• The surgery is a major stress on the patient, particularly in
older people • Complaints of dry mouth: otc, disease, chemotherapy

Hip replacement THE ESPOHAGUS

• In some hip fractures, the doctor completely removes the • Stiffening of the esophageal wall & less sensitivity to
head and neck of the femur, and replaces it with a prosthetic discomfort and pain
implant • Changes in the esophagus & pharynx: dysphagia, reflux,
heartburn, & chest pain
Nursing interventions
THE STOMACH
• Assess pain on a scale of 0 to 10 before and after
implementing measures to reduce pain • Decline in peristaltic contractions and emptying do not appear
• Administer narcotic per the physician’s order to be significant
• Perform neurovascular assessment every 2 to 4 hours, and • Gastric acid secretion is not affected by aging
document findings • Decline in pepsin, bicarbonate, sodium ion secretions &
• Appy straight leg traction per physician’s order prostaglandin: increased potential for mucosal injury in the
stomach
OSTEOMYELITIS
THE SMALL INTESTINES
• Infection of the bone that results in the inflammation,
necrosis, and formation of new bone • No change to minor changes in contraction intensity
• Causative agent penetration by different routes Decreased gastric emptying
(staphylococcus aureus and pseudomona spleces) Decreased gastric acid secretion + motility disturbances in
• Inflammatory response (increase vascularity and edema) the small intestines
• Extension of infection into the medullary cavity Bacterial overgrowth
• Sequestrum (abscess cavity containing dead bones) Malabsorption & malnutrition
develops
• Involucrum (new bone growth) development THE LARGE INTESTINES
• Recurring osteomyelitis by non-healing sequestrum
• 5 feet long when stretched
Classification • Loss of enteric neurons & nerve connections to the smooth
muscles occurs & increased fibrosis: longer colonic transit
• Hematogenous osteomyelitis – resulting from blood borne time
infection

15
• Increased colonic pressure – can be lowered by fiber
supplementation
THE LARGE INTESTINES
The rectumIncrease in fibrous tissue: reduced ability to
stretch as feces pass through
The anus Decreased motor neurons in the anal sphincter:
decline of control or contractile abilities
• Women – greater risk for anal sphincter changes
GASTRO ESOPHAGEAL REFLUX DISEASE
• Reflux of stomach acid into the esophagus
• Heartburn – pain produced in GERD
• Common on:
a. Men
b. Obese, smokers
• Worse after eating or lying down
• Aging increases the incidence of reflux

AGING IN ACCESSORY GLANDS AND ORGANS Signs & Symptoms

✓ Epigastric burning, worse after eating
THE LIVER ✓ Heartburn
✓ Burping (eructation) or flatulence
• Largest gland in the body ✓ Sour taste in mouth, often worse in the morning
• Secretes bile in the small intestines ✓ Nausea
✓ Bloating
• Screens blood from the stomach and small intestine for toxic
✓ Cough due to reflux high in the esophagus
substances, excess nutrients and ammonia ✓ Hoarseness or change in voice
• 30 – 40% decrease in blood flow and perfusion Treatment
✓ Administer antacids
THE GALLBLADDER
✓ Administer H2 (histamine type 2) blockers
• Stores bile from the liver ✓ Administer proton pump
✓ Have patient eat six small meals rather than three large
• Cholecystokinin – enzyme signaling the GB to release bile in
ones to reduce intraabdominal pressure.
the small intestines ✓ Surgery or endoscopic procedures may be performed to
prevent the reflux from occurring.
Delayed emptying rates in elderly clients
Nursing Interventions
Increased bile volume inside
✓ Monitor vital signs.
Predisposition to gallstones
✓ Assess abdomen for distention, bowel sounds.
➢ More common in OLDER WOMEN than men ✓ Teach about medication management.
THE PANCREAS ✓ Teach patient about lifestyle modifications:
✓ Not to lie down after eating.
• Secretes pancreatic fluid that neutralizes stomach acid & ✓ Elevate head of bed.
accelerates transport of large nutrients to the small intestines ✓ Avoid wearing clothing that is tight at waist.
✓ Avoid acidic foods (citrus, vinegar, tomato),
• Decrease in weight
peppermint, caffeine, alcohol.
• Fibrosis and cell atrophy ✓ Stop smoking.
✓ Lose weight if overweight
COMMON DISORDERS OF AGING
✓ More severe in elderly clients – should be treated
thoroughly
ESOPHAGEAL VARICES, BLEEDING

• One of the major causes of death in patients with cirrhosis GASTRITIS

• Dilated tortuous veins usually found in the submucosa of the
• Inflammation of the stomach lining due to either inflammation
lower esophagus or extend into the stomach
or atrophy
• Caused by portal hypertension
Erosion ✓ Stress (physical illness)
Signs and Symptoms
✓ Nonsteroidal anti-inflammatory drugs (NSAIDS)
✓ Hematemesis & melena
Atrophy ✓ Hx of prior sx
✓ Dilated veins
✓ Pernicious anemia
✓ If ruptured due to portal pressure:
✓ Alcohol use
✓ Cool clammy skin
✓ Helicobacter pylori
✓ Hypotension
✓ Tachycardia
Treatment Signs and Symptoms
✓ Evaluate extent of bleeding ✓ Nausea & vomiting Anorexia
✓ Oxygen ✓ Epigastric area discomfort
✓ IV fluids and volume expanders ✓ Epigastric tenderness on palpation due to gastric irritation
✓ Blood transfusion ✓ Bleeding from irritation of the gastric mucosa
✓ Non-surgical treatment is preferred due to high mortality with ✓ Hematemesis—possible coffee ground emesis due to
surgery partial digestion of blood
✓ Melena—black, tarry stool
Nursing Interventions
Treatment
✓ Evaluate emotional response
✓ Perform neurologic assessment ✓ Administer antacids:
✓ Monitoring for signs of hepatic encephalopathy ✓ Administer sucralfate to protect gastric lining.
✓ Treat bleeding by complete rest ✓ Administer histamine 2 blockers
✓ Assist patient to avoid straining and vomiting ✓ Administer proton pump inhibitors:
✓ Eradicate helicobacter pylori infection if present.

16
 ✓ Diet modification. INFLAMMATORY BOWEL DISEASE
✓ Monitor hemoglobin and hematocrit.
Nursing Interventions CROHN’S DISEASE
✓ Monitor vital signs.
✓ Monitor intake and output. • Regional enteritis
✓ Monitor stool for occult blood. • A non-continuous inflammatory disease that can affect any
✓ Assess abdomen for bowel sounds, tenderness. point from the mouth to the anus.
✓ Teach patient about: • The majority of cases involve the small and large intestine,
✓ Diet restrictions: avoid alcohol, caffeine, acidic foods. often in the right lower quadrant at the point where the terminal
✓ Medications. ileum and the ascending colon meet.
✓ The need to avoid smoking.
✓ The need to avoid NSAIDS. Signs And Symptoms
✓ Fever
PEPTIC ULCER DISEASE ✓ Right lower quadrant pain
• Erosion of the mucosal layer of the stomach or duodenum: ✓ Diarrhea (non-bloody)
contact of acid with the epithelial tissues ✓ Abdominal mass
✓ Weight loss (unintentional)
Gastric Lesser curvature of the stomach; occur more ✓ Fatigue
ulcer often in clients over age 40 ✓ Bloating after meals (postprandial)
Duodenal Deeper, penetrating through the mucosa to the ✓ Abdominal cramping due to spasm
ulcer muscular layer; tend to occur in people 20 – 40 ✓ Borborygmi (loud, frequent bowel sounds)
years of age ✓ Fistula formation (bowel-bowel, bowel- stomach, bowel-
bladder, bowel-skin, bowel-vagina)
Signs and Symptoms ✓ Aphthous ulcers (oral ulcerations)
✓ Epigastric area pain: ✓ Nephrolithiasis
✓ Worse just after eating as acid increases with gastric Treatment
ulcer ✓ Dietary restriction.
✓ Worse when stomach is empty (with duodenal ulcer); ✓ Nutritional supplementation.
may awaken during the night due to pain ✓ Administer vitamin b12 and folic acid.
✓ Weight changes: ✓ Administer aminosalicylates to induce or maintain remission
a. Loss with gastric ulcer ✓ Administer glucocorticoids to reduce inflammation
b. Gain with duodenal ulcer ✓ Administer purine analogs to induce or maintain remission
✓ Bleeding from ulcer causes: ✓ Administer methotrexate to induce or maintain remission.
✓ Hematemesis (vomiting bloody fluid— red, maroon); ✓ Administer antidiarrheal medications to decrease fluid loss;
more likely with gastric Ulcer ✓ Intravenous fluids to maintain hydration.
✓ Coffee-ground emesis (partially digested blood) ✓ Surgical correction of intestinal obstruction, fistula,
✓ Melena (tarry stool) more likely with duodenal ulcer perforation.
✓ Perforation of ulcer causes: Nursing Intervention
✓ Sudden, sharp pain ✓ Monitor vital signs for temperature increase, pulse increase,
✓ Tender, rigid, board-like abdomen and change in Blood pressure.
✓ Knee-chest position reduces pain ✓ Monitor intake and output.
✓ Hypovolemic shock ✓ Assess abdomen for bowel sounds, tenderness, masses.
Treatment ✓ Assess postoperative wound for signs of infection, drainage.
✓ Administer histamine-2 blockers ✓ Wound care postoperatively.
✓ Administer proton pump inhibitors ✓ Proper skin care if bowel-skin fistula:
✓ Administer mucosal barrier fortifiers ✓ Use of drainable pouch with skin wafer.
✓ Administer prostaglandin analogue ✓ Cleaning skin promptly if drainage comes in contact
✓ Adjust diet. with skin.
✓ Treat H. Pylori infection if present with combination ✓ Nutritional supplementation with ensure
therapy: ✓ Teach patient about home care needs.
✓ Proton pump inhibitor plus clarithromycin plus
amoxicillin or ULCERATIVE COLITIS
✓ Proton pump inhibitor plus metronidazole plus
clarithromycin • Recurrent ulcerative and inflammatory disease of the mucosal
✓ Bismuth subsalicylate plus metronidazole plus and submucosal layer of the colon and rectum
tetracycline. • Serious disease accompanied by systemic complications &
Nursing Interventions high mortality rate
✓ Monitor vital signs. • 10 – 15% develops carcinoma of the colon
✓ Monitor intake and output.
✓ Assess abdomen for bowel sounds, tenderness, rigidity, Signs And Symptoms
rebound pain, guarding. ✓ Diarrhea
✓ Monitor stool for change in color, consistency, blood. ✓ Abdominal pain
✓ Teach patient about home care: ✓ Intermittent tenesmus
✓ Diet modification to avoid acidic foods, caffeine, ✓ Ineffective straining at stool
peppermint, alcohol. ✓ Rectal bleeding
✓ Eat more frequent, small meals. ✓ Pallor, if bleeding is severe
✓ Avoid nonsteroidal anti-inflammatory medication. ✓ Anorexia, fever, vomiting, dehydration, cramping
✓ Stop smoking. ✓ Hypocalcemia, and anemia

17
 Treatment CHOLECYSTITIS
✓ Reduce inflammation
✓ Provide rest for the diseased • Acute complication of cholelithiasis
✓ Diet and fluid intake • Acute infection of the gallbladder
✓ Pharmacologic therapy
✓ Psychotherapy (factors that distress the patient) Gallstone
✓ Surgical management Obstruction of bile outflow
Compromise of vascular supply
DIARRHEA Gangrene

• A condition defined by an increase in the frequency of bowel Signs And Symptoms

movements (>3x/day) ✓ May be silent – no pain and only mild GI symptoms
• Increased amount of stool (>200g/day) ✓ Fullness abdominal distention, vague upper right quadrant
• Altered consistency (liquid stool) pain after high-fat meal
✓ Fever
Signs And Symptoms ✓ Jaundice, accompanied by marked itching with obstruction of
✓ Increased frequency and fluid content of stool the common bile duct
✓ Abdominal cramps, distention, intestinal rumbling ✓ Very dark urine, clay-colored stool
(borborygmus), anorexia, and thirst Treatment
✓ Painful spasmodic contractions of the anus and ineffectual ✓ Surgery-Stone removal
straining (tenesmus) with each defecation ✓ Surgical intervention for disease of the biliary tract is the most
✓ Elderly clients have an increase in bacteria in the GI system, common operation performed for the elderly
resulting in diarrhea ✓ Cholecystectomy is usually tolerated and carries a low risk
✓ Watery stool: small bowel disease Nursing Interventions
✓ Loose, semi-solid stools: disorders of the colon ✓ Post-op - Place client in high-fowler’s position
✓ Voluminous greasy stools: intestinal malabsorption ✓ Provide IV fluids
✓ Mucus and pus in the stool: inflammatory enteritis or colitis ✓ Provide water and other fluids and soft diet, after bowel
✓ Oil droplets on toilet paper: pancreatic insufficiency sounds return
✓ Nocturnal diarrhea: diabetic neuropathy ✓ Promote early ambulation
Treatment ✓ Relieve pain
✓ Control symptoms, prevent complications, and ✓ Improve respiratory status
eliminate/treat underlying disease ✓ Improve nutritional status – avoid excessive fat
✓ Medications: Antibiotics, anti-inflammatory agents
✓ Increase oral fluid, oral glucose & electrolyte solutions
✓ Antidiarrheals HEPATIC CIRRHOSIS
✓ Diphenoxylate (lomotil)
✓ Loperamide (imodium) • Chronic disease characterized by replacement of normal liver
✓ IV therapy for rapid rehydration tissue with diffuse fibrosis that disrupts the function of the liver

Types of Hepatic Cirrhosis

CONSTIPATION
a. Alcoholic (most common)
• Abnormal infrequency or irregularity of defecation
b. Postnecrotic
• Abnormal hardening of stools (difficult and painful)
c. Biliary
• Decrease in stool volume
• Develops when people do not take the time to defecate or as Signs And Symptoms
a result of dietary habits, lack of exercise, and a stress-filled ✓ Liver enlargement in early course (fatty liver)
life ✓ Liver size decrease in later course
✓ Ascites
Signs And Symptoms ✓ GI varices
✓ Abdominal distension, pain, and pressure ✓ Edema
✓ Decreased appetite, headache, fatigue, ✓ Vitamin deficiency (A, C, & K) and anemia
indigestion, sensation of incomplete emptying ✓ Mental deterioration
✓ Straining at stool (hard, dry stool) Treatment
✓ Complications: Hypertension, hemorrhoids & ✓ Supportive – based on the symptoms
fissures, fecal impaction, and megacolon ✓ Antacids
Treatment ✓ Vitamins
✓ Discontinue laxative abuse ✓ Balanced diet
✓ Increase fluid intake, include fiber in the diet ✓ Nutritional supplements
✓ Exercise to strengthen abdominal muscles ✓ K-sparing diuretics (for ascites)
✓ If laxatives is necessary, fecal softeners ✓ Avoidance of alcohol
✓ Colchicine – increases length of survival with mild to
Cholelithiasis moderate cirrhosis

Cholelithiasis (gallstones) – forms in the gallbladder from solid PANCREATITIS

constituents of bile and vary greatly in shape, size, and
composition: Pigment stone & Cholesterol stones • Inflammation of the pancreas

18
 Acute 1. Autodigestion of the pancreas by pancreatic
enzymes
2. Fibrosis
3. Blood glucose control may be affected
Chronic 1. Recurrent episodes of exacerbation
2. Fibrosis and decrease in pancreatic function
Signs And Symptoms
✓ Epigastric pain
✓ Boring abdominal pain may radiate to back or left shoulder
in acute pancreatitis
✓ Gnawing continuous abdominal pain with acute
exacerbations in chronic pancreatitis
✓ Patient in knee-chest position for comfort
✓ Nausea and vomiting
✓ Bluish-gray discoloration of periumbilical area and abdomen
(cullen’s sign)
✓ Bluish-gray discoloration of flank areas (turner’s sign)
✓ Ascites
✓ Weight loss
✓ Blood glucose elevation
✓ Fatigue
Treatment
✓ NPO during acute stage to reduce release of pancreatic
enzymes.
✓ Intravenous fluids for hydration.
✓ Total parenteral nutrition.
✓ Pain management with narcotics during acute stage.
✓ Avoid morphine that may increase pain due to spasm of the
sphincter of odd
WEEK 15: NEUROLOGIC SYSTEM CHANGES
OVERALL STRUCTURAL CHANGE: THE AGING BRAIN
Decrease in size and weight
• Birth – 357 gms
• 20 – 55 yrs – 1,300 gms (peak)
• 55 yrs – starts to decline
Brain volume – stable from age 20 – 60 then declines
• Men > women = volume loss in brain as a whole and temporal
(hearing and speaking) and frontal lobe (speaking, emotions,
and judgement)
• Women > men = volume loss in the hippocampus
(responsible for learning and memory) & parietal lobes
(sensory information; five senses)
Neurocortical neurons
• Female – 19 billion
• Males – 23 billion
• Perception, decision-making, and judgement.
• 10% of neurocortical neurons are lost over the lifespan
• Significant decline of neurons in the cerebrum (voluntary
movement, vision, hearing & other senses)
• Minimal neuronal loss in the cerebellar cortex and basal
ganglia (muscle movement and control)
Brain stem
• some loss of neurons in the nucleus of Meynert
(acetylcholine production – chief neuro transmitter and
parasympathetic transmitter, dilate and contract muscle,
decrease heart rate; responsible for attention and loc)
• locus of coeruleus (norepinephrine production – same with
adrenaline, increase bp, sugar level, heart rate); sends signal
from the brain to different portion of the body; controls
breathing and unwanted movement.
Myelin sheath
• Sends electrical signals to the neurons
• breaks down in aging
• Helps to explain mild age-related declines in cognition and
motor control
SYNAPSE – no significant change; messenger system between
the dendrites and axon.
a. Axon – take away information from the old body parts
b. Dendrites, that carry impulses and bring information to the
brain
Compensatory mechanism
• Plasticity – ability to lengthen and/or form new neuronal
connections onto available existing neurons; diminish with
age, but is not completely lost
NEUROTRANSMITTER CHANGES
• Neurotransmitter – chemical messenger from the axons into
the synaptic space & onto corresponding receptors on the
postsynaptic neuron
• Changes on memory and cognition, as well as behavior and
motor function
CHOLINERGIC
• Cholinergic neurons
a. Neurotransmission of acetylcholine
b. Learning and memory in humans
c. Induces learning and memory
d. Declines in level
• More pronounced in Alzheimer’s disease – acetyl
cholinesterase inhibitor (medication) = decrease degradation
of acetylcholine
DOPAMINERGIC
• Involves dopamine
• Levels and transport in the neuron decreases (10% per
decade)
• Parkinson’s disease (brain disorder; uncontrolled movement)
– marked decrease in dopamine = diminished motor control &
compromised cognitive performance
MONOAMINERGIC
• Consists of norepinephrine and serotonin
• Norepinephrine – responsible for alertness; Increase with
age, although there is decreased receptors
• Serotonin – stabilize the mood, responsible for happiness and
sleeping
a. Decrease with age
b. Depression and sleep changes later in life
AMINO ACID TRANSMITTERS
• Glutamate – excitatory in the brain and central nervous
system; responsible for concentration
a. Major excitatory neurotransmitter
19
 b. Glutamate receptors decline • Slower in detecting and recognizing stimuli – making actions &
• Gamma-aminobutyric acid (GABA) – relaxation reactions more difficult
a. Major inhibitory neurotransmitter
b. Unknown age-related change NEUROLOGIC DISORDERS
c. Decrease is correlated with aggressive behavior
ALZHEIMER’S DISEASE
NEURO ENDOCRINE CHANGES
VASCULAR CHANGES • Most common type of dementia seen in older adults
• Characterized by progressive memory loss.
• Cerebral blood flow decreases with age = decreased utilization • A terminal disease that over its course will eventually leave a
of glucose and metabolic rate of oxygen person completely dependent upon others for care; this is not
• Blood-brain barrier – age-related degradation of capillary walls normal
= inability of oxygen and nutrients to enter the brain
DESCRIPTION
PLAQUES AND TANGLES ✓ An estimated 5% of the people who are over 65 years old.
Have the severe form of Alzheimer’s; 12% suffer from mild
• Hallmarks of Alzheimer’s disease (type of dementia) to moderate dementia.
• But both can be found in older individuals without dementia ✓ Typically, patients die of debilitating brain disease 2 – 15
• Aging brain: plaques are disseminated years after the onset of the signs and symptoms. (average
of 8 years)
• Alzheimer’s – plaques are numerous and dense
✓ Amyloid plaques and dense of formation that can be seen in
The aging spinal cord: nerve conduction the MRI
SIGNS AND SYMPTOMS
• Cells -remains stable until 60 years old = Then declines after ✓ Restlessness at night
60 yo ✓ Incontinence, emaciation, irritability, coma (late
manifestations)
Bone overgrowth ✓ Short-term memory impairment is often the first sign
narrowing of the aging spine ✓ Language disturbance
pressure on the spinal cord ✓ Decline in motor skills
changes in sensation ✓ Loss of abstract thought process
✓ Visual processing impairment
✓ Repetitive actions
THE AGING PERIPHERAL NERVOUS SYSTEM
TEN WARNING SIGNS OF ALZHEIMER’S
• Slow nerve conduction – degradation of the myelin sheath 1. Memory loss
• Calcium disregulation – loss of cell viability in nervous tissue 2. Difficulty performing familiar tasks
3. Problems with language
• Age-related changes in the PNS can explain changes in motor 4. Disorientation to time and place
speed, & sensory abilities 5. Poor or decreased judgement
6. Problems with abstract thinking
SENSORY NEURONS
7. Misplacing things
• Declines – alterations in reflexes and voluntary actions & 8. Changes in mood or behavior
9. Changes in personality
certain quality areas (memories, thoughts, and emotion)
10. Loss of initiative
• Touch TREATMENT
a. Meissner’s corpuscles & pacinian corpuscles – decreases ✓ No cure for AD
• Olfactory neurons – Decrease with age ✓ Tacrine is the only drug approved by the FDA for AD
• Taste – Salty taste has greatest decline with age treatment – 6 to 12 months
✓ Cholinesterase inhibitors – stops the progression of the
SOMATIC MOTOR NEURONS disease
✓ SSRIs for depression – selective-serotonin inhibitors
• Decrease in number - reduction in the number of muscle cells ✓ Antipsychotics for agitation
= consequent muscle degeneration and weakness ✓ Hypnotics for difficulty sleeping
• Changes in the myelin sheath & cell membrane damage - ✓ Vitamin E to improve cognition
slower relay of message = alters ability of the muscle to NURSING INTERVENTIONS
contract and relax ✓ Safety
• These changes can be lessened by daily exercise aimed at ✓ But try to maximize what abilities they do have
increasing and retaining the performance of remaining ✓ Prevent any further progression
muscles
DEMENTIA
AUTONOMIC MOTOR NEURONS
• A general term that refers to progressive, degenerative brain
• Changes include both sympathetic (fight and flight) & dysfunction, including deterioration in memory, concentration,
parasympathetic (state of calmness) pathways language skills, visuospatial skills, and reasoning, that
• Delayed response (body temperature and blood pressure) interferes with a person’s daily functioning • Not considered
part of normal aging
INJURY RESPONSIVENESS

• Decreased

20
SIGNS AND SYMPTOMS Stage SEVERE
Behavior ✓ Difficulty in to ambulate or engage in motor
• Having difficulty recalling recent events. activities
• Not recognizing familiar people and places. ✓ Decreased swallowing activities
• Having trouble finding the right words to express thoughts or ✓ Complete self- care deficits
name objects. Affect ✓ Flat, apathetic
• Having difficulty performing calculations. ✓ Occasional catastrophic actions may continue
• Having problems planning and carrying out tasks Cognitive ✓ Progression of cognitive changes with
changes increased severity of amnesia, agnosia,
• Having trouble exercising judgment
apraxia, and aphasia
• Having difficulty controlling moods or behaviors.
• Depression is common, and agitation or aggression may
TREATMENT
occur.
• Not keeping up personal care such as grooming or bathing. • Cholinesterase inhibitors (ceis)
• Donepezil (aricept)
Delusions 20-73%
• Rivastigmine (exelon)
Hallucinations 15-29%
• Galantamine (razadyne)
Hostility 20%
Depressive symptoms 80% • N-methyl-d-aspartate (NMDA) receptor antagonists
• Memantine (namenda)

Behavioral and Psychological Symptoms NURSING INTERVENTIONS

Behavioral Symptoms Psychological Symptoms • Promote comfort

✓ Physical aggression
✓ Verbal agitation
✓ Physical agitation
✓ Wandering
✓ Sexual disinhibition
✓ Hoarding
✓ Verbal aggression
✓ Shadowing
STAGES OF DEMENTIA OF THE ALZHEIMER’S TYPE
✓ Anxiety • Promote function
✓ Depressive symptoms • Promote dignity
✓ Hallucinations • Speak to your patient in a soft, calm, low-pitched voice
✓ Delusions
✓ Paranoia PARKINSON’S DISEASE
• One of the most common neurological diseases
• Usually affects people over the age of 50 • “Shaking palsy”
• A degenerative, chronic, and slowly progressing disease with
no known etiology

Stage MILD PATHOPHYSIOLOGY

Behavior ✓ Difficulty completing tasks
✓ Decline in goal- directed activity • Degeneration of the basal ganglia 
✓ Lack of attention to personal appearance • loss of neurons in the substantia nigra
✓ Withdrawal from usual social activities • decreased production of dopamine
✓ Frequent searching for misplaced objects
✓ May accuse others of stealing SIGNS AND SYMPTOMS
Affect ✓ Anxious
✓ Depressed • Four cardinal signs:
✓ Frustrated 1. Bradykinesia
✓ Suspicious 2. Rigidity
✓ Fearful 3. Tremor
Cognitive ✓ Recent memory losses 4. Gait changes
changes ✓ Time disorientation
✓ Decreased ability to concentrate TREATMENT
✓ Difficulty making decisions
✓ Poor judgment • Medications:
a. Levodopa
Stage MODERATE b. Carbidopa (sinemet) – decreases SE of nausea
Behavior ✓ Socially inappropriate behavior c. Selegiline
✓ Self-care deficits d. Permax
✓ Wandering and pacing e. Parlodel
✓ Hoarding objects • Deep brain stimulation
✓ Hyperorality • Thalamotomy
✓ Disturbance in sleep and wake cycle
• Adult stem cells
Affect ✓ Labile mood
• Drug alert: Because of age-related changes affecting
✓ Flat, apathetic
✓ Paranoia pharmacodynamics and pharmacokinetics, older patients
Cognitive ✓ Recent and remote memory losses (amnesia) receiving antiparkinsonian drugs are at increased risk for
changes ✓ Confabulation developing adverse reactions!!!
✓ Disorientation to time, place, and person
✓ Some degree of agnosia, apraxia, and aphasia NURSING INTERVENTIONS

• Teach the patient & family

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 a. Safety promotion response to stimuli (highest score 15) – 8 and below = coma
b. Prevention of falls state
c. Disease progression ✓ Motor – 6
d. Mobility ✓ Eye opening – 4
e. Bowel and bladder, potential swallowing problems ✓ Verbal – 5
f. Sleep promotion ✓ Monitor for signs of increased intracranial pressure
g. Communication ✓ Notify healthcare provider of changes in neurologic status.
✓ Develop a means of communication with the patient
STROKE ✓ Assess for neglect syndrome
✓ Need for rehabilitation to return to prior functional ability.
• Aka cerebrovascular accident (CVA) ✓ Explain to the patient:
• Interruption of blood supply to the brain that may lead to ✓ Proper technique to transfer from bed to chair.
neurological damage, disability, or death ✓ Use of ambulatory assist devices: cane, crutch, walker.
✓ Medication schedule, use, side effects, and interactions
DESCRIPTION
✓ Recovery depends on how quickly and completely WEEK 16: Critical Care and Emergency Nursing
circulation is restored HEMODYNAMICS
✓ Usually due to thrombosis (most common cause),
embolism, or hemorrhage • Components Of Hemodynamics
RISK FACTORS • BP
✓ Tia • CVP
✓ Atherosclerosis • R/L heart pressures
✓ Hypertension
✓ Arrhythmia Review of CIRCULATORY SYSTEM
✓ Mi CHARACTERISTICS OF THE HEART
✓ Rhd
✓ High serum cholesterol, lipoprotein, or TG ACTIVITY ELECTRICAL MECHANICAL
✓ Cardiac hypertrophy CONTRACTION Depolarization Systole
✓ Emboli RELAXATION Repolarization Diastole
✓ Dm
✓ Gout Atrial kick – the contraction of the atria forcing the remaining atrial
✓ Obesity blood into the ventricles *30% contribution to CO
✓ Lack of exercise
✓ Family hx Stroke volume (SV)
SIGNS AND SYMPTOMS • Volume of blood ejected during systole.
✓ Mental impairment • Amount of blood ejected per heartbeat
✓ Disorientation, confusion
✓ Emotional changes, personality changes Cardiac Output (CO) – amount of blood ejected from the heart in
✓ Aphasia 1 minute
✓ Slurring of words Formula: SV x HR = CO
✓ Sensory changes
✓ Unilateral numbness or weakness in face or limbs a. 4-8 L/min
✓ Seizure b. 5 L/min
✓ Severe headache due to increased intracranial pressure
from hemorrhage Left ventricular end-systolic volume (LVESV) – amount of blood
✓ TIA symptoms are similar but have a shorter duration and that remains in the left ventricle at the end of the contraction.
resolve after contraction (50 ml; 16 - 143 ml)
TREATMENT
✓ Administer TPA (thromoblytic agent) within 3 hours of onset Left ventricular end-diastolic volume (LVEDV) – amount of
of symptoms, blood that is in the ventricle just before ejection occurs. before
✓ Administer anticoagulants for patients with ischemic stroke contraction
✓ administer anti-platelet medications to decrease platelet 120 ml; 65 - 240 ml
adhesiveness
✓ Administer corticosteroid to decrease swelling Ejection fraction (EF) – portion of blood the left ventricle ejects.
✓ Physical therapy to help maintain muscle tone or return 70% of the total volume
function.
✓ Speech therapy to help with speech and swallowing. BLOOD PRESSURE – Tension exerted by blood on the arterial
✓ Occupational therapy to help regain function. walls.
✓ Bed rest to reduce chance of injury. Blood Pressure = CO X SVR
✓ Adequate nutrition in appropriate food type for patient.
✓ Stenting of carotid artery to maintain blood flow. SYSTEMIC VASCULAR RESISTANCE – Opposition to the blood
✓ Surgical correction of arteriovenous malformation (common flow from the blood vessel
cause of stroke to young), aneurysm, intracranial bleeding
NURSING INTERVENTIONS Causes of SVR
✓ Monitor vital signs for changes. • Increase Vasoconstriction
✓ Assess neurological status for signs of deterioration— • Increase Catecholamines
perform neurological checks at least every 4 hours— • Decrease Sepsis
typically use Glasgow coma scale or similar tool to grade • Decrease Neurologic

22
PRELOAD b. Inflated – measures PCWP
✓ Nursing Interventions:
• Amount of cardiac muscle stretch at the end diastole just ✓ Provide patient education
before contraction. ✓ Consent form
• Dependent on the blood volume returning to the heart ✓ Setting up equipment
• Measured by PAWP (Pulmonary artery wedge pressure) ✓ Prepare the line
✓ Assisting physician
AFTERLOAD ✓ Monitoring pressure
✓ Making clinical decisions (accdg. to hospital policy)
• Amount of resistance against which the ventricle pumps. ✓ Monitor complication
• Measured by BP and arterial tone
• influenced by blood vessels, blood viscosity, flow patterns, and SHOCK TRAUMA
valves
• Decrease tissue perfusion
Contractility – strength of myocardial fiber shortening during • Decrease BLOOD FLOW
systole. • Decrease O2 → ISCHEMIA
Frank-Starling Law – “The greater the stretch, the greater the STAGES OF SHOCK
force of the next contraction” STAGE I: Compensatory stage (BP) normal
Heart rate – number of heart beat per minute. • Increase HR
Inotropism – ability to influence contractility of muscle fibers • Increase RR – due to metabolic acidosis

Hemodynamic Monitoring STAGE II: Progressive

✓ Measurement of pressures of the cardiovascular and
• MAP falls below normal
circulatory system
✓ Goals Of Hemodynamic Monitoring: Mean Arterial Pressure:
✓ Ensuring adequate perfusion
✓ Detecting inadequate perfusion Clinically hypotensive
✓ Titrating therapy to specific end point
✓ Qualifying the severity of illness 1. Respiratory
✓ Differentiating system dysfunction a. Rapid and shallow RR
Direct Arterial Blood Pressure Monitoring b. Crackles
✓ Allows for accurate, continuous monitoring of arterial BPs c. decrease pO2 & increase pCO2
✓ Most accurate d. ARDS or “shock lung”
✓ Site: radial, brachial, femoral, dorsalis pedis 2. CV – dysrhythmias and ischemia > chest pain
✓ COMPLICATIONS: 3. Neurologic effects
✓ Thrombosis
4. Hepatic effects - less able to metabolize meds
✓ Embolism
a. liver enzymes elevate → jaundice
✓ Blood loss
✓ Infection 5. GIT effects - stress ulcers---GI Bleeding
Right Atrial Pressure Monitoring 6. Hematologic effects – hypotension
✓ Location: a. sluggish blood flow > DIC
✓ SVC / IVC – CVP 7. Renal effects
✓ RA - RAP a. ARF – BUN & crea acid-base imbalance
Left Atrial Pressure Monitoring b. UO
✓ Indications: Management:
✓ cardiac surgical procedures
✓ cardiac catheterization lab a. ECG, hemodynamic monitoring, ABG’s, Mechanical vent,
✓ post- open heart surgery hemodialysis
✓ Major complications:
✓ embolism STAGE III: Irreversible or Refractory
✓ thrombolism
• Organ damage severe
Pulmonary Artery Monitoring
✓ Multi-lumen, balloon-tipped catheter inserted through the • Patient unlikely to survive
venous system into the R side of the heart into the
MODS
✓ Site:
a. MULTIPLE
✓ Antecubital vein
✓ External jugular vein b. ORGAN
✓ Subclavian artery c. DYSFUNCTION
✓ Other peripheral vein d. SYNDROME
✓ Key notes:
✓ Fluoroscopy not required Sign and Symptoms OF SHOCK
✓ Insertion – deflated Compensatory Progressive Irreversible;
✓ RA – inflated Refractory
✓ Pressure reading: LOC Confusion Lethargy Unconscious
- If balloon is: Skin Cold clammy Mottled Jaundiced
a. Deflated – measures PA

23
 RR Greater than 20 Rapid and Requires Neurogenic shock
shallow intubation • Loss of sympathetic tone
HR > 100 > 150 Asystole • Peripheral pooling of blood
BP Normal Systole: below Requires • causes:
80-90 pharma a. SCI,
support b. Spinal anesthesia,
c. Lack of glucose
OVERALL MANAGEMENT
NI:
1. Fluid replacement- restore intravascular volume
2. Vasoactive medications-improve cardiac function • elevate and maintain HOB at least 30 degrees when patient is
3. Nutritional support – address metabolic requirements receiving spinal or epidural anesthesia
a. Requires > 3,000 cal/day • SCI- immobilize
FLUID REPLACEMENT Anaphylactic shock
1. Crystalloids – move freely between IV & interstitial spaces • caused by severe allergic reaction
0.9% sodium chloride (NS) & LR • Antigen – Antibody reaction
2. Colloid – IV solution large molecule • Mast cells release Histamine
a. Albumin: prepared from human plasma; • And bradykinin → vasodilation
b. Dextran: not indicated if hemorrhage is caused of
• Ex: Bee sting, latex allergy
hypovolemic shock
• Transfusion rxn
➢ Complications of Fluid administration: pulmonary edema
ICP- INTRA CRANIAL PRESSURE
DRUGS
Monro-Kellie hypothesis
1. Sympathomimetics
• Blood- 75
➢ Drugs Enhancing Myocardial Contractility (beta1 agonist)
➢ Improve heart muscle cell contraction dobutamine • Brain-1400g
(Dobutrex) • CSF- 75
2. Vasoconstricting Drugs: ↑ CO & MAP Causes:
➢ epinephrine,
➢ norepinephrine (Levophed): • Head injury
a. ↑ CO & MAP • Infxn- CNS
b. BP= CO x TPR • Tumor-brain
c. SV x HR • Stroke
TYPES OF SHOCK Increased ICP results to Dec perfusion
HYPOVOLEMIC SHOCK Dec O2, increased CO2- resp acidosis
paCO2 >45 normal co2 35-45
• blood-- hemorrhage fluid loss
pH <7.35
• NI: Administering blood & fluids safely
Vasodilation
Internal Fluid Shifts ✓ Hemorrhage Cerebral edema
✓ Burns Sign and symptoms of Increased ICP
External Fluid loss ✓ Trauma
✓ Surgery Sign and symptoms of Increased ICP
✓ Vomiting
✓ Diuresis, DI • Earliest sign – Change in LOC
• Pupillary changes, headache
CARDIOGENIC SHOCK • Cushing’s reflex
Risk Factors: a. HPN
b. bradycardia
• Coronary –more common c. Wide Pulse Pressure
• Non-coronary • ICP Cushing’s triad
• Tension pneumothorax, a. Hypertension, increase T
• Valve damage, Cardiomyopathy b. Bradycardia
c. Bradypnea
CIRCULATORY/DISTRIBUTIVE SHOCK • Increased CP
a. Late manifestations: inc. BP, T ,dec. HR, RR
• Occurs when blood volume is abnormally displaced in the
b. Widened Pulse Pressure
vasculature
c. Abnormal posturing: Decorticate, Decerebrate
• Septic shock- infxn
d. Loss of pupillary, corneal, gag reflexes
• Anaphylactic shock
• Shock
• Neurogenic shock a. Hypotension, decrease T
b. tachycardia
c. tachypnea

24
Diagnostic:
• CT, PET, SPECT, MRI Cerebral Angiography
Avoid LP
Medical Mgt
• Maintain BP & oxygenation
• Dec. cerebral edema- Osmotic diuretic- Mannitol
• Draining CSF Restricting fluid,controlling fever 
• Complications of ICP:
a. Brain stem herniation
b. SIADH
c. DI
NI with INC. ICP
• Maintain patent airway
a. Elevate HOB, Suction with care
b. Avoid coughing
• Achieve an Adequate Breathing Pattern
a. Monitor respiratory irregularities
b. Maintain PaCO2 level <30 mmHg
• Optimizing cerebral tissue perfusion
a. Head kept neutral
b. Enemas, Valsalva avoided
• Maintaining negative fluid balance
a. Osmotic & loop diuretics
b. Anaphylaxis – a life threatening hypersensitivity or
pseudoallergic reaction to an exogenous agent.
Terminologies:
• Cardiogenic shock – due to decreased functioning of the
heart, which leads to decrease forward flow of oxygenated
blood to the tissue.
• Hemodynamics – study of forces involved in the flow of blood
through the cardiovascular and circulatory systems.
• Hypovolemic shock – inadequate circulating blood volume in
the intravascular bed. • shock – distributive shock
characterized by tachycardia, hyperthermia or hypothermia,
and hypotension caused by decreased SVR.
WEEK 17: LAWS AFFECTING SENIOR CITIZEN
Republic act No. 344 or the Accessibility Law of 1982 –
provides for the minimum requirements and standards to make
buildings, facilities, and utilities for public use accessible to persons
with disability, including older persons who are confined to
wheelchair and those who have difficulty in walking or climbing
stairs, among others.
RA 7432 – known as “an act to maximize the contribution of senior
citizens to nation building, grant benefits and special privileges and
for other purposes”.
Republic Act No. 7432 or “An Act Establishing a senior Citizens
Center in all Cities and Municipalities of the Philippines, and
Appropriating Funds Therefore” – provides for the establishment of
senior Citizens Centers to cater to older persons’ socialization and
interaction needs as well as to serve as a venue for the conduct of
other meaningful activities.
Republic Act No. 8425 – provides for the institutionalization and
enhancement of the social reform agenda by creating the National
Anti-Poverty commission (NAPC). Through its multi-dimensional
and cross- sectoral approach, NAPC provides a mechanism for
older persons to participate in policy formulation and decision-
making on matters concerning poverty alleviation.
Republic Act No. 9994. “Expanded Seniors Citizen Act of
2010”- an act granting additional benefits and privileges to senior
citizens, further amending Republic Act No. 7432 and otherwise
known as “an act to maximize the contribution of senior citizens to
nation building, grant benefits and special privileges and for other
purposes.
Republic Act No. 10155, “The General Appropriations Act of
2012” – under Section 28 mandates that all government agencies
and instrumentalities should allocate one percent of their total
agency budget to programs and projects for older persons and
persons with disability
Republic Act No. 10645, An Act Providing For the Mandatory
Philhealth Coverage for All Senior Citizens”, Amending for the
purpose, Republic act No. 7432, as amended by Republic Act No.
9994 by removing the qualification that a senior citizen has to be
indigent before being covered by PhilHealth
Republic Act No. 10868, “Centenarians Act of 2016”, An Act
Honoring and Granting Additional Benefits and Privileges to a
FILIPINO CENTENARIANS. All Filipinos who have turned
centenarian in the current fiscal year shall be awarded a plaque of
recognition and a cash incentive by their respective city or
municipal governments in appropriate ceremonies in addition to the
LETTER of FELICITATION and centenarian gift of P 100,000.00.
Aside from DSWD, other agencies involved in the implementation
of the law’s provisions are Department of the Interior and Local
Government (DILG), Department of Health (DOH), and
Commission on Filipinos Overseas (CFO).
Presidential Proclamation No. 470, Series of 1994, declares the
first week of OCTOCER of every year as “Elderly Filipino Week.”
Presidential Proclamation No. 1048, Series of 1999, declaring a
“Nationwide Observance in the Philippines of the International
Year of Older Persons”.
Executive Order No. 105, series of 2003, approved and directed
the implementation of the program providing for group homes and
foster homes for neglected, abandoned, abused, detached, and
poor older persons and persons with disabilities.
The Philippine Plan of Action for senior Citizens (2011-2016).
This plan aims to ensure giving priority to community-based
approaches which are gender-responsive, with effective leadership
and meaningful participation of senior citizens in decision-making
processes, both in the context of family and community.
ETHICS OF CARE include compassion, equity, fairness, dignity,
confidentiality, and mindfulness of a person’s autonomy within the
realm of the person’s abilities and mental capacity.
ETHICAL PRINCIPLES
1. ADVOCACY – refers to loyalty and a championing of the
needs and interest of others, to educate and informed the
patients about their rights and access benefits entitled for
them.
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2. AUTONOMY- is the concept that each person has a right to
make independent choices and decisions.
3. BENEFICENCE / NONMALEFICENCE- These concepts of
do good (beneficence) and do no harm (nonmaleficence) are
integral to health care.
4. CONFIDENTIALITY – emphasizes respect for human dignity
that is demonstrated in daily work.
5. FIDELITY – refers to keeping promises or being true to
another, being faithful to commitments and responsibilities.
6. FIDUCIARY RESPONSIBILITY – refers to using both fiscal
reserves and caregiving resources wisely, potentially requiring
a cost-benefit analysis to facilitate decision making.
7. JUSTICE – refers to fairness of an act situation
8. QUALITY AND SANCTITY OF LIFE – quality of life is a
perception based on personal values and beliefs, sanctity of
life referring to the value of life and the right to live.
9. RECIPPROCITY – is a feature of integrity concerned with the
ability to be true to one’s self while respecting and supporting
the values and views of another.
10. VERACITY – means truthfulness and refers to telling the truth,
or at the least, not misleading or deceiving patients or their
families.
ISSUES TO BE CONSIDERED
These are:
• Issues on Conflict of interest
• Issues on Confidentiality
• Issues on decision-making capacity
Issues on Conflict of Interest
1. Actual Conflict of Interest issues – between family
members and caregivers represent the elderly or assist them
in decision-making.
These include conflicts:
a. Between spouses and the elder’s wishes and interest;
b. Between family members and the elder’s wishes and interest;
c. Between a guardian, conservator or other lawfully designated
agent and the elder’s wishes and interests;
d. Between a caregiver’s business interests and the elder’s
interests. Well-being and quality of life.
2. Perceived Conflicts of Interest – which include those which
are not actual conflicts in the course of care but may later
become conflicts when the elder patient’s interest diverge from
those who provide the care.
Issues on Confidentiality
• In caring for an elderly patient, invariably, there is disclosure
made by the family and relatives regarding information that
may otherwise be personal and confidentiality to the patient
alone.
Issues on Decision- Making Capacity
• Many times, the older patient’s decision-making capacity ( also
referred to as “ competence”) may be required for certain
decisions.
DEATH AND DYING
LOSS
• An actual or potential situation in which something that is
valued is changed, no longer available or gone.
• Parting with an object, person, belief or relationship that one
values.
• Loss of body image, significant other, a sense of well-being, a
job, personal possessions, beliefs, a sense of self. etc.
Types of Loss:
1. Personal loss – Any significant loss of someone or something
that can no longer be seen or felt, heard, known or
experienced & that requires individual adaptation through the
grieving process.
2. Perceived loss – Loss that is less tangible & uniquely defined
by the grieving client (loss of confidence, prestige)
a. Experienced by one person but cannot be verified by
others.
3. Maturational loss – Change in developmental process that is
normally expected during a lifetime.
a. Loss that occur on the process of normal development.
4. Situational loss – Loss of a person, thing or quality resulting
from a change in a life situation, including changes related to
illness, body image, environment and death.
a. Any sudden, unexpected and definable event that is not
predictable.
5. Actual loss – Can be identified by others & can arise either in
response to or in anticipation of a situation.
a. Any loss of a person or object that can no longer be felt,
heard, known, or experienced by the individual.
GRIEF
• The total response to the emotional experience related to loss
which is usually resolved within 6 months to 2 years.
• Sorrow manifested in thoughts, feelings, & behaviors
occurring as a response to an actual or perceived loss.
• Permits individual to cope with the loss gradually & to accept
it as part of reality; a social process best shared & carried out
with assistance of others.
• May be experienced as a mental (anger, guilt, anxiety,
sadness & despair); physical (sleeping problems, difficulties in
swallowing, vomiting, fatigue, headaches, dizziness, fainting,
blurred vision, skin rashes, excessive sweating, menstrual
disturbance, palpitations, chest pain, dyspnea, changes in
appetite, physical problems, weight loss, or illness); social
(feelings about taking care of others in the family, seeing
family or friends, or returning to work, or emotional reaction
(depression, etc.)
Types of Grief:
1. Abbreviated grief – Grief which is brief but genuinely felt; lost
may not have been sufficiently important to the grieving person
or may have been replaced immediately by another, equally
esteemed object.
2. Anticipatory grief – Process of accomplishing part of the grief
work before an actual loss; grief response in which the person
begins grieving process before an actual loss.
26
3. Dysfunctional grief Signs of Impending Death
➢ Occurs when there is prolonged emotional instability,
withdrawal from usual task or activities that previously Loss of Muscle Tone
gave pleasure & lack of progression from one level to ✓ Relaxation of the facial muscles (jaw may sag)
successful coping with the loss. ✓ Difficulty speaking
➢ Extended grief, unsuccessful use of intellectual and ✓ Difficulty swallowing & gradual loss of the gag reflex.
emotional responses by which individuals attempt to work ✓ Decreased activity of the GIT, with subsequent nausea,
through the process of modification. accumulation of flatus, abdominal distention & retention of
feces.
Dysfunctional Grief may be: ✓ Possible urinary & rectal incontinence due to decreased
sphincter control
a. Unresolved Grief - extended in length and severity, bereaved
✓ Diminished body movement
may also have difficulty expressing the grief, may deny the
Slowing of the Circulation
loss or may grief beyond expected time; severe chronic grief
✓ Diminished sensation
reaction in which the person does not complete the resolution
✓ Mottling & cyanosis of the extremities
stage of the grieving process within a reasonable time.
✓ Cold skin, first in the feet and later in the hands, ears and
b. Inhibited Grief – many of normal symptoms of grief are
nose (however the client may feel warn due to elevated
suppressed and other effects, including somatic are
temperature)
experienced instead.
Changes in Vital Signs
Grieving process ✓ Decelerated and weaker pulse
✓ Decreased BP
• Sequence of affective, cognitive & physiological states through ✓ Rapid shallow, irregular, or abnormally slow respirations;
which the person responds to and finally accepts an Cheyne strokes respirations; noisy breathing, referred to as
irretrievable loss. death rattle due to collecting of mucus in the throat; mouth
breathing, which leads to dry oral mucus membranes.
Bereavement
Sensory Impairment
• The subjective response experienced by the surviving loved ✓ Blurred vision
ones after the death of a person with whom they have shared ✓ Impaired sense of taste & smell (hearing is the last sense to
a significant relationship. disappear)
• Experience alterations in libido, concentration, patterns of
eating, sleeping, activity and communication. Clinical Signs of Death

Concepts which help the Nurse to Plan for Interventions: Cessation of the apical pulse, respirations and blood pressure.

1. Mourning – The behavioral process through which grief is
eventually resolved or altered.
a. Process by which people adapt to a loss which is
influenced by cultural, customs, rituals, and society’s rules
for coping with loss.
2. Hope – Characterized by a confident, yet uncertain
expectation of achieving a goal.
3. Closure – The point at which the loss has been resolved and
the grieving individual can move on with life without focusing
on the loss.
Sources of Loss
1. Loss of Aspect of Self – Any change the person perceives
as negative in the way the person relates to the environment
is loss of self.
2. External Object – Loss of inanimate object that has
importance to the person (ex. Jewelry, money, etc…)
3. Accustomed Environment – Separation from an
environment and people who provide security.
4. Loved Ones – Loss of valued person or loved ones through
illness, separation, divorce, broken relationship, moving,
running away, promotion at work, or death.
5. Loss of Life – Physical death, brain death, ability to reason.
a. Concern is not about death itself but about pain and loss
of control, fear of separation, abandonment, loneliness or
mutilation.
1. Total lack of response to external stimuli.
2. No muscular movement, especially breathing.
3. No reflexes.
4. Flat encephalogram for 24 hours.
CEREBRAL DEATH
• Occurs when the higher brain center, the cerebral cortex, is
irreversibly destroyed.
• It is believed that the cerebral cortex, which holds the capacity
for thought, voluntary action & movement, is the individual.
BODY CHANGES
1. Rigor Mortis
a. Stiffening of the body that occurs about 2 to 4 hours after
death due to lack of Adenosine Triphosphate (ATP),which
is not synthesized because of a lack of glycogen in the
body.
b. Starts in the involuntary muscles (heart, bladder, etc.)
then progresses to head, neck, trunk and finally reaches
the extremities.
c. Leaves the body about 96 hours after death.
2. Algor Mortis
a. Gradual decrease of the body’s temperature after death.
b. When blood circulation terminates and the hypothalamus
ceases to function, body temperature falls about 1 degree
Celsius per hour until it reaches room temperature.

27
3. Livor Mortis
a. Bluish discoloration of the skin after death.
b. After blood circulation has ceased, skin becomes
discolored.
c. The RBC breakdown, releasing hemoglobin, which
discolors the surrounding tissues.
4. Embalming
a. Injection of chemicals in the body to destroy the bacteria.
b. Tissues after death become soft & eventually liquefied by
bacterial fermentation.
c. The hotter the temperature, the more rapid the change,
therefore, bodies are often stored in cool places to delay
the process.
STAGES OF DEATH AND DYING
(Elizabeth Kubler-Ross, 1969, 1974)
Denial
✓ It is the immediate response to loss experienced by most
people and it is a useful tool for coping.
Anger
✓ The client has no control over the situation and thus
becomes angry in response to this powerlessness.
✓ The angry may be directed at self, God, and others
Bargaining
✓ The anticipation of the loss through death brings about
bargaining through which the client attempts to postpone
or reverse the inevitable.
Depression
✓ When the realization comes that the loss can no longer be
delayed, the client moves to the stage of depression.
✓ It helps the client detach from life to be able to accept
death.
Acceptance
✓ The final stage of acceptance may not be reached by every
dying client, however, “most dying persons eventually
accept the inevitability of death, many want to talk about
their feelings with family members:
✓ Verbalization of emotions facilitates acceptance
Promotion of Comfort
1. Relief of pain is critically important, the sooner the dying client
obtains pain relief, the more energy the client can direct toward
maintaining quality in the remainder of his life.
2. Provide personal hygiene measures, control pain, relief
respiratory difficulties, assists with movements, nutrition,
hydration and elimination, provide measures related to
sensory changes.
Promotion of Spiritual Comfort
1. Support client in his expression of the philosophy he has
chosen for his life.
2. Attentive listening encourages client to express feelings,
clarify them, and accept his fate.
3. Praying silently with the client.
4. Make referral for spiritual counseling.
5. Facilitate expression of feeling, prayer, meditation, reading,
and discussion with appropriate clergy/spiritual advisor.
Care of the Body
1. Placed in supine position with arms at the side, palms down,
or across the abdomen (to make the body look as natural and
comfortable as possible).
2. Place a small pillow or folded towel under the heads (to
prevent discoloration from blood pooling).
3. Gently hold eyelids close for a few seconds to make it remain
close.
4. Insert client’s dentures to maintain the normal facial features.
5. Place a rolled-up towel under the chin to keep mouth closed.
6. Wash any soiled body parts, dress the body in a clean gown,
and cover the body up to the shoulders with clean linen.
7. Place absorbent pads under the perineal and rectal area to
collect any oozing feces or urine.
8. Remove all jewelries and present it and any valuables to the
family.
9. If the weeding band is left in place, tape it securely to the
finger.
10. Allow family members to enter the room when body is
prepared never allow a single family member to enter the room
alone (for emotional support).
11. Special tags containing the deceased’s name, hospital
number, and name of the attending physician are placed on
the wrist and ankles and on the outside of the shroud.
12. In the morgue, body is placed in a special cooling unit to slow
decomposition.
Death Certificate
• Made out when a person dies, usually signed by the attending
physician and filled with a local health or other government
office.
• Family is given a copy to use for legal matters.
Labeling of the Deceased
• If appropriately identified and prepared incorrectly can create
legal problems.
• Placed on the wrist, ankle, and on the shroud.
• Contains name of deceased, Hospital number and name of
attending physician.
Autopsy or Postmortem Examination
• An examination of the body after death and is performed only
in certain cases:
a. When death is sudden or occurs within 48 hours of
admission to a hospital, the organs and tissues of the
body are examined to establish the exact cause of death.
b. To learn more about the disease.
c. To assist in the accumulation of statistical data.
• Consent should be obtained by the physician from the decent
(before death) or by the next of kin (surviving spouse, adult
children, parents, siblings)
• Hospitals cannot retain any tissues or organs without the
permission of the person who consented to the autopsy
Terminal illness is a disease that will result in the death of the
patient regardless of any treatment intervention. A patient is
considered terminally ill when their estimated life expectancy is six
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months or less, under the assumption that the disease will run its 2. Ask the patient what he needs or what would make him more
normal course. comfortable. Perhaps this is music, special books or a visit
from a certain person. Try to meet any requests the patient
When Symptoms May Be Normal Sadness has. If a request is not possible to fill, ask the patient if there is
Grief is a normal part of the dying process. Feelings that are anything else you can do as a substitute.
common among terminally ill patients may include: 3. Arrange to help the immediate family. Perhaps the spouse
could benefit from having meals prepared and brought to him
a. Deep sadness and regret (this may include crying or sobbing) so he can be at his wife's bedside. Child care might be needed.
b. Anger Reducing stress from the patient's loved ones can also reduce
c. difficulty sleeping or changes in appetite the cancer victim's stress.
d. Fatigue 4. Offer to record messages for the patient. Some patients might
e. Restlessness wish to leave a video message for young children, unborn
f. Disbelief grandchildren or others, which could be nothing more than a
g. Disengagement or apathy legacy of who he is.
5. Be present. If your friend or loved one is afraid to die, be there
(When normal feelings of grief become excessive and start to for her. If you can't be present, arrange for others to sit with
interfere with every aspect of a person’s life, they may indicate a her through her fear. You can only do so much and be there
more serious problem.) so much, but your presence or the presence of another person
When Symptoms May Be Depression can be very comforting to a terminally ill cancer patient.
6. Incorporate things the patient likes into visits. If the patient
The symptoms of depression in terminally ill patients often loves flowers, bring in fresh flowers for a visit. If the patient
correspond with symptoms of their disease, making it all the more loves a certain cookie, bring this if it's allowed. If the patient
difficult to diagnose. Symptoms to watch for include: loves to read but no longer can, bring a book on CD for her to
listen to.
a. Severe mood swings or other mood disturbances 7. Offer comfort and as much understanding as possible. Don't
b. Prolonged difficulty sleeping pretend to understand what the patient is going through. You
c. Prolonged difficulty eating haven't died, and left loved ones so you don't know what it is
d. Loss of interest in once pleasurable activities or hobbies like to face certain death. Hugs and even holding a hand
e. Feelings of helplessness might bring the patient much comfort.
f. Feelings of guilt
g. Persistent worrying
h. Suicidal ideation

When Symptoms May Be Side Effects of Medication

Many medications may cause symptoms that might be mistaken

for depression. They include:

• Changes in appetite and weight gain or loss

• Dry mouth (“cotton mouth”)
• Disturbance in sleep patterns
• Fatigue or a decrease in energy

Risk Factors for Depression in the Elderly

• A history of chronic illness

• A personal or family history of depression
• Substance abuse
• Poorly controlled pain
• Lack of social support system
• Recent bereavement
• Difficulty adjusting to stressful situations
• Brain disease
• Decreased mobility
• Certain medications
• Physical and cognitive decline

CARING FOR TERMINALLY ILL PATIENT

1. Offer to listen and hear what the patient has to say. Avoid
being judgmental, and prepare to hear a variety of emotions,
including anger and frustration.

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