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Midterm Notes
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Week 7: Core Elements of Evidence-Based
Gerontological Nursing Practice
With the formalization and growth of the gerontological nursing specialty, nurses and
nursing organizations have developed informal and formal guidelines for clinical
practice. Some of these core elements include evidence-based practice and standards and
principles of gerontological nursing.

EVIDENCE-BASED PRACTICE
There was a time when nursing care was guided more by trial and error than sound
research and knowledge. Fortunately, that has changed, and nursing now follows a
systematic approach that uses existing research for clinical decision making – a process
known as evidence-based practice. Testing, evaluating, and using findings in the nursing
care of older adults is of such importance that it is among the ANA Standards of
Professional Gerontological Nursing Performance.

Evidence-based practice relies on the synthesis and analysis of available information

from research. Among the more popular ways to report this information are the meta-
analysis and cost-analysis (Agency for Health Care Research and Quality, 2008). Meta-
Analysis is a process of analyzing and compiling the results of published research studies
on a specific topic. This process combines the results of many small studies to allow
more significant conclusions to be made. With cost-analysis reporting, cost-related data
are gathered on outcomes to make comparisons. Performance also can be compared with
best practices or industry averages through a process of benchmarking.

1. Standards

2. Competencies

3. Principles

Midterm Notes 1
 4. Issues/Concerns

AMERICAN NURSES ASSOCIATION

Published a statement on the scope of gerontological nursing practice in 1970.

Defines nature and scope of gerontological nursing.

Purposes:

Health Promotion

Health Maintenance

Disease Prevention

Self-Care

SCOPE OF PRACTICE OF GERONTOLOGICAL NURSE

They specialize in the nursing care and health needs of older adults.

They plan, manage, and implement health care to meet those needs and evaluate the
effectiveness of such care.

The primary challenge is to identify and use the strengths of older adults, and to
assist them in maximizing their independence.

They must actively involve older adults and family members in decision-making
process, which has a great impact on the everyday quality of life of the patient.

ROLES OF THE GERONTOLOGICAL NURSE

1. Provider of Care. Know the disease process, signs & symptoms, and risk factors to
provide a quality care.

2. Teacher/Educator. Providing health teaching.

3. Manager. Balance the concerns of relatives, healthcare providers, and patients.

4. Advocate.

5. Research Consumer. All the interventions that we are doing are evidence-based.
We also assist in research process (data collection).

STANDARDS OF CLINICAL GERONTOLOGICAL

NURSING CARE
STANDARD I: ASSESSMENT

Midterm Notes 2
 Subjective Data - verbalized by the client (primary) or verbalized by the relative of the
client (secondary).

Objective Data - observed by the nurse through physical examination or laboratory

results.

STANDARD II: DIAGNOSIS

NANDA is used by nurses to diagnose patients. It can be problem-focused, health
promotion, or risk.

Problem-Focused: Has problem-related factors and defining characteristics.

Health Promotion: Has problems and signs/symptoms; focused on promoting

health.

Risk: Risk factors are present.

Syndrome: 1 or more diagnoses.

STANDARD III: OUTCOME IDENTIFICATION

This should be specific, measurable, attainable, realistic, and time-bound.

STANDARD IV: PLANNING

Identify the appropriate interventions:

Independent - carried out by the nurse without prescription/order.

Dependent - requires prescription/doctor’s order.

Collaborative - collaborate with other healthcare providers for the plan of care.

STANDARD V. IMPLEMENTATION
Prioritize interventions formulated in the planning phase.

STANDARD VI. EVALUATION

Client’s response to the interventions.

CORE COMPETENCIES
Provide a foundation of added knowledge and skills necessary for the nurse to implement
in daily practice.

Midterm Notes 3
 This was developed by the AACN and the John A. Hartford Foundation Institute for
Geriatric Nursing entitled, “OLDER ADULTS: Recommended Baccalaureate
Competencies and Curricular Guidelines for Geriatric Nursing Care.” This serves as
guide to nursing professors to prepare students to be competent to provide excellent care
to older adults.

1. Critical Thinking: Logically decide in different cases/scenario.

2. Communication

3. Assessment

4. Technical Skills

ROLE DEVELOPMENT

Provider of Care.

Designer/Manager/Coordinator of Care.

Member of a Profession.

CORE KNOWLEDGE

Health promotion, risk reduction, and disease prevention.

Illness and disease management.

Information and healthcare technologies.

Ethics.

Human diversity.

Global healthcare.

Health care system and policy.

COMPETENCIES AND CURRICULAR GUIDELINES FOR GERIATRIC

NURSING CARE

Recognize one’s own & others’ attitudes, values, and expectations about aging &
their impact on care of older adults & their families.

Adopt the concept of individualized care as the standard of practice with older
adults.

Communicate effectively, respectfully, and compassionately with older adults and

their families.

Midterm Notes 4
 Recognize that sensation and perception in older adults are mediated by functional,
physical, cognitive, psychological, and social changes common to old age.

Incorporate into daily practice valid and reliable tool to assess the functional,
physical, cognitive, psychological, social, and spiritual status of older adults.

Assess older adults’ living environment with special awareness of the functional,
physical, cognitive, psychological, and social changes common to old age.

Analyze the effectiveness of community resources in assisting older adults and their
families to retain personal goals, maximize function, maintain independence, and
live in the least restrictive environment.

Assess family’s knowledge of skills necessary to deliver care to older adults.

Adapt technical skills to meet the functional, physical, cognitive, psychological,

social, and endurance capacities of older adults.

Individualize care and prevent morbidity and mortality associated with the use of
physical and chemical restraints in older adults.

Prevent or reduce common risk factors that contribute to functional decline,

impaired quality of life, and excess disability in older adults.

Establish & follow standards of care to recognize and report elder mistreatment.

Apply evidence-based standards to screen, immunize, and promote healthy activities

in older adults.

Recognize and manage geriatric syndromes common to older adults.

Recognize the complex interaction of acute and chronic co-morbid conditions

common to older adults.

Use technology to enhance older adults’ function, independence, and safety.

Facilitate communication as older adults transition across and between home,

hospital, and nursing home, with a particular focus on the use of technology.

Assist older adults, families, and caregivers to understand and balance “everyday”
autonomy and safety decisions.

Apply ethical & legal principles to the complex issues that arise in care of older
adults.

Appreciate the influence of attitudes, roles, language, culture, race, religion, gender,
and lifestyle on how families and assistive personnel provide long-term care to older
adults.

Midterm Notes 5
 Evaluate differing international models of geriatric care.

Analyze the impact of an aging society on the health care system.

Evaluate the influence of payer system on access, availability, and affordability of

health care for older adults.

Contrasts the opportunities and constraints of a supportive living arrangement on the

function and independence of older adults and on their families.

Recognize the benefits of interdisciplinary team participation in the care of older

adults.

Evaluate the utility of the complimentary and integrative health care practices on
health promotion and symptom management for older adults.

Facilitate older adult’s active participation in all aspects of their own health care.

Involve and educate, and when appropriate, supervise family, friends, and assistive
personnel in implementing best practices for older adults.

Ensure quality of care commensurate with older adults’ vulnerability, frequency, and
intensity of care needs.

Promote the desirability of quality end-of-life care for older adults, including pain
and symptom management, as essential, desirable, and integral components of
nursing practice.

PRINCIPLES OF GERONTOLOGICAL NURSING PRACTICE

Aging is a natural process common to all living organisms.

Various factors influence the aging process.

Unique data and knowledge are used in applying the nursing process to the older
population.

Older adults share similar self-care and human needs in all other human beings.

Gerontological nursing strives to help older adults achieve wholeness by reaching

optimum levels of physical, psychological, social, and spiritual health.

PROMOTING HEALTHY AGING (HEALTHY PEOPLE

INITIATIVE)
An initiative of the US Department of Health and Human Services that set forth
healthcare objectives designed to increase the quality and quantity of years of healthy life
of Americans and to eliminate health disparities.

Midterm Notes 6
 The focus is to minimize the loss of independence associated with illness and functional
decline.

COMPONENTS OF HEALTH PROMOTION FOR THE ELDERLY

EXERCISE

Regular exercise and physical activity can improve health in a variety of ways:

Reduction in heart disease, diabetes, high blood pressure, colon cancer,

depression, anxiety, excess weight, bone thinning, muscle wasting, and joint
pain.

Nursing Implications:

Motivate the elderly to have regular exercise and increase their physical
activity.

Advise the elderly to have continuous exercise.

Promote the physical activity and exercise as a habit for the elderly.

NUTRITION

Eating and drinking habits have been implicated in 6 out of 10 leading cause of
death in the elderly.

Older adults are more prone to either obesity or malnutrition.

Nursing Implications:

Proper Nutrition

Alcohol Consumption: Men twice a day and women once a day.

Decrease fats and decrease cholesterol diet.

Balance caloric intake.

Daily calcium, vitamin B12, vitamin D, fruits, and vegetables.

Calcium and Vitamin D supplements may cause renal problems or

renal stones. It can be increased through diet but avoid supplements.

MENTAL HEALTH

Decreased life satisfaction due to:

Decreased income (50%).

Increased emotional losses.

Midterm Notes 7
 Physical losses.

Caregiving responsibilities.

Nursing Implications:

Life Review: Tool for preserving or enhancing the mental health of the older
adults.

Life Domains: Aspects and experiences of life.

Autobiography, tape recording, or video tapes.

Depression:

Losses accompanying aging such as widowhood, chronic medical conditions

and pain, and functional dependence.

Depression may lead to physical decline.

Plays a significant role in suicidal behaviors.

Undetected in the elderly.

MODEL HEALTH PROMOTION PROGRAMS FOR OLDER ADULTS

Programs that have received federal funding and foundation supports to evaluate
their effectiveness and to encourage their replication.

The focus is on older adults.

Health Wise: Provides information and prevention tips on 190 common health
problems.

Chronic Disease Self-Management Program: Founded by nurse researcher

Kate Lorig. Self-management program of chronic diseases.

Project Enhance: Enhance fitness and enhance wellness.

Ornish Program for Reversing Heart Disease: Founded by Dr. Dean Ornish.
It involves enhancement of elderly nutrition.

Benson’s Mind/Body Medical Institute: Founded by Dr. Herbert Benson. It is

a combination of relaxation, nutrition, exercise, and reframing from negative
thinking patterns.

Strong for Life Model: Exercise program for disabled and non-disabled older
adults.

SAFETY

Midterm Notes 8
 Falls are the leading cause of unintentional injury death in older adults.

Elderly people are vulnerable to falls as a result of:

Postural Instability

Decreased Muscle Strength

Gait Disturbances

Decreased Proprioception

Visual/Cognitive Impairment

Polypharmacy

Environmental Conditions: Slippery surfaces, stairs, irregular surfaces, poor

lighting, incorrect footwear, or obstacles in the pathways.

FALL RISK ASSESSMENT: “I HATE FALLING”

Inflammation of joints/joint deformity.

Hypotension (Orthostatic Blood Pressure Changes)

Instruct client to sit on the edge of the bed for 10-15 minutes before
standing up.

Auditory and Visual Impairments

Tremors

Equilibrium Problems

Foot Problems

Arrhythmias, Heart Blocks, Valvular Disease

Leg Discrepancy

Lack of Conditioning (General Weakness)

Illness

Nutrition

Gait Disturbances

DISEASE PREVENTION
Helps prevent functional decline.

LEVELS OF DISEASE PREVENTION

Midterm Notes 9
 1. Primary Prevention: Designed to completely prevent a disease from occurring.

2. Secondary Prevention: Early detection and management of disease.

3. Tertiary Prevention: Manage clinical disease in order to prevent them from

progressing or to avoid complications of the disease.

QUALITY OF LIFE
How a person rates his or her life as satisfactory or not.

Degree of satisfaction and dissatisfaction with life.

According to WHO (1994), an individual’s perception of his or her position in life in the
context of their culture and value system where they live in and in relation to their goals,
expectations, standards, and concerns.

QUALITY OF LIFE MODEL

Physical Well-Being: Functional ability, strength/fatigue, sleep/rest, nausea,

appetite, and constipation.

Psychological Well-Being: Anxiety, depression, enjoyment, leisure, pain, distress,

happiness, fear, and cognition/attention.

Social Well-Being: Caregiver burden, roles and relationships, affection/sexual

function, and appearance.

Spiritual Well-Being: Suffering, meaning of pain, religiosity, and transcendence.

QUALITY OF LIFE PROGRAM

Active Aging

Integrated health and quality of life program.

Optimizing opportunities for health, participation in the community and safe

living in order to enhance quality of life.

Center of Active Being: Provide quality of life to the elderly.

Enhance autonomy, independence, and activity.

WHO’S DETERMINANTS OF HEALTH

Affects aging and the quality of life of individuals, communities, and nations.

Behavioral Determinants:

Midterm Notes 10
 1. Physical Activity: contributes to muscle strength, flexibility, balance,
cardiovascular health, positive mood, and improves cognition.

2. Nutrition: Powerful and modifiable lifestyle factors. Increase in vitamins and

minerals, increase in vitamins B6, B12, D, K, and folic acids. Increase in anti-
oxidants such as vitamins A, C, E, beta-carotene, selenium, calcium, and iron.

3. Smoking: Single most important preventable risk factor that causes premature
death (5A’s: ask, advice, assess, assist, and arrange).

4. Alcohol Abuse and Alcoholism: Elderly have the increased effects of alcohol
because of pharmacologic changes associated with aging.

FOUR STEPS IN TREATING ALCOHOLISM:

1. Identify individuals requiring treatment.

2. Determine individual’s readiness to discuss treatment.

3. Assess individuals requiring detoxification.

4. Plan for post-detoxification treatment in coordination with other

professionals.

5. Medication Adherence: Non-adherence to medication and invisible epidemic

(clients with substance abuse).

RISK FACTORS:

Polypharmacy

Physical Impairments

Cognitive Limitations

Limited Access to or Affordability of Healthcare Services

Low-Literacy Patients

STRATEGY:

Promote self-efficiency.

Empower patients to become informed medication consumers.

Avoid strategies that could intimidate.

Help the patient to develop a list of short-term and long-term goals.

Plan for a regular follow-up.

Implement a reward system.

Midterm Notes 11
 Personal Determinants:

Biological

Genetic Impacts

Psychological Determinants:

Intelligence

Cognitive Capacity

Physical Determinants:

Safe Housing

Social Determinants:

Social Support

Violence & Abuse

Education & Literacy

Economic Determinants:

Income

Wealth

Neighborhood Conditions

Social Services Determinants:

Nonmedical factors that influence health outcomes.

They are the conditions in which people are born, grow, work, live, and age, and
the wider set of forces and systems shaping the conditions of daily life.

Week 8: Ethico-Legal Considerations in the

Care of Older Adult
LAWS AFFECTING OLDER ADULTS/SENIOR
CITIZENS
REPUBLIC ACT NO. 344

Accessibility Law of 1982

Midterm Notes 12
 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.

REPUBLIC ACT NO. 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. 7876

“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 person’s

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

Midterm Notes 13
 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 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 OCTOBER 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.

REPUBLIC ACT NO. 9257

It shall train community-based health workers among senior citizens and health
personnel to specialize in the geriatric care and health problems of senior citizens.

PHARMACOLOGY AND OLDER ADULTS

Midterm Notes 14
 Older persons are at a greater risk for adverse drug events than younger persons because
of differences in the body's utilization of drugs. Persons 65 and older are prescribed the
highest proportion of medication in relation to their percentage.

More appropriate predictors of medications response include general state of health,

number, and types of other medications taken liver and renal function, presence of co-
morbidities or other diagnosed diseases.

CHANGES WITH AGING

Decrease in body water (as much as 15%) and an increase in body fat.

Decreased concentration of water-soluble drugs (e.g., Alcohol).

More prolonged effects of fat-soluble drugs.

Decreased hepatic blood flow.

Changes in pharmacodynamics in the older person may be caused by decreases in the

number of receptors and receptor binding.

Decrease in serum albumin level.

Leads to altered binding capacity.

May cause increased serum levels of the "free" or unbound proportion of protein-
bound drugs.

May result in toxic levels of highly bound drugs because more unbound drug is
available to produce its effects.

INAPPROPRIATE ADMINISTERED MEDICATIONS TO OLDER ADULT

Prescriptions for long-acting benzodiazepines, persantine.

Long-term use of drugs that are to be used for short-term use only (e.g., histamine
blockers, short-acting benzodiazepines, oral antibiotics).

High doses of drugs prescribed above dosage limitations (iron supplements,

histamine blockers, antipsychotic agents).

Decreased hepatic blood flow results in increased toxicity = Increased SGPT,

Increased PT, and PTT.

Results in increased toxicity when older persons take usual doses of "first-pass
effect" drugs because a smaller portion of these drug concentrations would be
detoxified immediately by the liver.

AGING AND DRUG THERAPY

Midterm Notes 15
 Persons 65 and older are prescribed the highest proportion of medication in relation
to their percentage.

Older person’s body use of drugs place them at greater risks for adverse drug events
than younger persons.

The kidneys excrete most drugs and individuals vary in degree of

decline of renal function.

OLDER ADULT’S RESPONSE TO MEDICATION

A person’s biological age alone is a poor predictor of how an older person will react
to a medication.

More appropriate predictors of medication response include:

General state of health.

Number and types of other medications taken.

Liver (SGPT) and renal (creatinine) function.

Presence of comorbidities or other diagnosed diseases.

Physiological responses to medications may also depend on the race or ethnic

background of older person.

MEDICATION ERROR

It may be related to: Prescribing, Dispensing, Administering, or Monitoring of Drug.

Root Cause: Attributed to human knowledge based deficiencies and a lack of

sophisticated systems to support and monitor drug therapy.

2 IMPORTANT DISTINCTIONS IN MEDICATION ERROR LANGUAGE

Adverse Drug Reaction (ADR)

Any noxious, unintended, and undesired effects of a drug which occurs at doses
in human for prophylaxis, diagnosis or therapy.

ADR Clues May Include:

Difficulties in the activities of daily living

Cognitive changes

Falls

Anorexia, nausea

Midterm Notes 16
 Weight changes

Adverse Drug Event (ADE)

Any injury that results in medications used, and this includes both ADRs and
medication errors that lead to an ADR.

The use of too many wrong types of medications increases the risks of both of
an ADE and non-adherence.

Factors that Contribute to Increased Risk of ADE:

Pharmacokinetic Changes

What the body does to the drug.

These include changes in:

1. Drug Absorption - age-related changes in drug absorption do not

usually contribute to a significantly altered drug response and are
generally thought to have less significant impact on pharmacokinetics.

2. Drug Distribution (Protein-Binding) - drug distribution into the

peripheral circulation and tissues is altered as a function of age.

A decrease in plasma albumin levels with age may result in

decreased binding of drugs that or mainly bound to serum
albumin.

A decrease in total body water and intracellular water volumes

may lead to an increased serum concentration of water-soluble
drugs such as lithium or alcohol.

An increase in body fat may increase the distribution of fat-soluble

medications such as benzodiazepine into fatty tissue, resulting in
prolonged half-lives and drug accumulation.

Also relies on the bioavailability of the drug.

3. Hepatic Metabolism

Age-related changes in hepatic drug metabolism are not easily

measured.

Biotransformation occurs in all body tissues but primarily in the

liver, where enzymatic activity alters and detoxifies the drug to
prepare it for excretion.

4. Renal Excretion

Midterm Notes 17
 The most important pharmacokinetic parameter that changes with
age. Although the change in renal function is extremely variable,
the majority of older adults have a decline kidney function. This
may require a decreased dose or extension of the dosing interval
for certain drugs.

Serum creatinine may be used as indirect estimate of renal

function by calculating creatinine clearance.

Creatinine Clearance (ml/min) = 140 – Age (in years) x Weight in

Kilograms 72 x Serum creatinine (mg/dl).

For women, multiply final result by 0.85

Creatinine Levels – Male: 0.7 – 1.7 mg/dl ; Female: 0.4 – 1.4

mg/dl .

Creatinine clearance is an estimate of Glomerular Filtration

(GFR) and decreases with age.

Blood Urea Nitrogen (BUN) – 7-23 mg/dl. Used as the gross

measure of glomerular function and the production and excretion
of urea.

Alkaline Phosphatase – 34-122 u/l ; Indicator of liver disease.

Pharmacodynamic Changes

What the drug does to the body.

Aging may result in different responses for older adults to the same
drug concentrations at the site of action compared with those observed
in younger adult.

Causes of Changes in Pharmacodynamics in Older Person:

1. Altered number of receptors or affinity

2. Decreases in receptor binding

3. Altered cellular responses to the drug-receptor interaction

4. Organ pathologic condition

5. Altered homeostatic mechanisms

Drug-Food Interactions

Midterm Notes 18
 The presence or absence of any food that may reduce or increase the
bioavailability of a medication, leading to unanticipated effects.

Examples:

Theophylline and Caffeine – increased potential for toxicity.

Levodopa and Clonidine – decreased antiparkinsonian effect.

Drug-Drug Interactions

An interaction between one drug and another can result from altered
pharmacokinetics or pharmacodynamics.

It is largely thought that alterations in hepatic metabolism are

specifically responsible for drug-drug interaction.

Example:

Warfarin and Aspirin - increased risk for bleeding.

Drug-Disease Interactions

Certain disease states may be exacerbated by specific drug therapies,

and these drugs may be contraindicated in patients with a coexisting
underlying disease.

Example:

Aspirin, NSAIDs, and Atrophic Gastritis – GI hemorrhage.

Polypharmacy

Prescription, administration, or use of more medications than are

clinically indicated in a given patient.

Multiple medications increase the chance of:

Drug-drug interactions

ADEs and ADRs

Errors of dosing

Prevention of Polypharmacy:

Use of the same pharmacy to fill all prescriptions

Notification to all prescribing clinicians of drugs used, including:

➢ Prescribed medications

Midterm Notes 19
 ➢ Herbal remedies
➢ OTC medications
➢ Dietary supplements
➢ Vitamins

Antipsychotic drugs should not be used unless necessary.

FEDERAL LEGISLATIONS IN PROBLEMS WITH MEDICATION

USE IN NURSING FACILITIES
ONNIBUS BUDGET RECONCILIATION ACT (OBRA) 1987

Legislated the appropriate use of medications in institutionalized older persons.

Use of chemical restraint

Use of unnecessary drugs

Antipsychotic drugs should not be used unless necessary to treat a specific condition
that is diagnosed and documented in the clinical record.

BEERS CRITERIA

Commonly used concensus criteria related to inappropriate medications.

Developed in 1997 and adopted in 1999 by the centers of medicare and medical
services for the regulation of medications in nursing homes.

COMMONLY USED MEDICATIONS

ANXIOLYTICS & HYPNOTICS

Anxiety can be a significant problem in older persons and is often associated with
depression & dementia.

According to the Beer's list, benzodiazepines with long half-lives should be avoided
because of the likelihood of accumulation of the patient drug and its active
metabolite, resulting in increased toxicity.

Daily use of both long- and short-term acting benzodiazepines:

✓ Should be limited to less than 4 continuous months.
✓ Should be limited unless an attempt at gradual dose reduction is unsuccessful.
✓ Dose reductions should be considered after 4 months.
ANTIDEPRESSANTS

Midterm Notes 20
 All antidepressants are generally equally effective and typically take effect in 2 to 4
weeks.

Overall, tricyclic antidepressants should be avoided in the older patient because of

their anticholinergic and sedative side effects profile.

The newer SSRIs are often considered the first choice for antidepressants in older
adults because of their lack of TCA side effects.

ANTIPSYCHOTICS

Should be prescribed only when valid and clear documentation of need exists, since
many side effects occur with use of these agents.

Appropriate indications for antipsychotic prescription include schizophrenia,

paranoid states, and symptoms of psychosis such as hallucinations and delusions.

3D's that may justify antipsychotic use:

✓ Danger to the resident or others.
✓ Distress for the resident.
✓ Dysfunction of the resident, including interference with basic nursing care.
Conditions where inappropriate antipsychotic drug use are possible:

Wandering

Poor self-care

Restlessness

Impaired memory

Anxiety

Depression

Insomnia

Unsociability

Indifference to surroundings

Fidgeting

Nervousness

Uncooperativeness

Agitated behavior when not a danger to self or others

Midterm Notes 21
 Residents who use antipsychotic drugs should receive:

1. Gradual dose reductions.

2. Drug holidays.

3. Behavioral programming unless clinically contraindicated.

PRN Dose of Neuroleptics:

Are not to be used more than twice in a 7-day period without further assessment
unless for the purpose of titrating dosage for optimal response unless for
management of unexpected behaviors otherwise unmanageable.

CARDIOVASCULAR MEDICATIONS

The main concerns with the use of cardiovascular medications in older adults are an
increased risk of orthostatic hypotension and dehydration, especially with volume-
depleting agents and vasodilators.

ANTIMICROBIALS

Dosing of antibiotics may need to be altered in older clients because of reduced

renal elimination.

NONPRESCRIPTION AGENTS

FDAs division of over-the-counter drug evaluation considers three main criteria

when reviewing an request to switch a prescription product to OTC status:
▪ A record of established safety data for the prescription product is necessary.
▪ The drug's expected use should be appropriate for OTC treatment.
▪ The drug should lack undesirable properties and not require speciaL precautions
when used without physician oversight.

SLEEP AND THE OLDER ADULTS

Proper sleep architecture and adequate total sleep time are necessary for
proper functioning.

BIOLOGIC BRAIN FUNCTIONS RESPONSIBLE FOR SLEEP

1. Hypothalamus

2. Thalamus

Midterm Notes 22
 3. Limbic System

AGE-RELATED CHANGES IN SLEEP

Increased sleep latency

Reduced sleep efficiency

Increased nocturnal awakenings

Increased daytime sleepiness

Greater difficulty falling asleep

More frequent awakenings

Decreased amounts of nighttime sleep

More frequent daytime napping

Increased time spent trying to sleep as sleep becomes less efficient

AGE-RELATED CHANGES IN THE NERVOUS SYSTEM AFFECTING SLEEP

Declines in the cerebral metabolic rate and cerebral blood flow.

Reductions of neuronal cell counts.

Structural changes such as neuronal degeneration and atrophy.

SLEEP REQUIREMENTS

A common myth is that you require less sleep as you age.

Most older adults require 6-10 hours of sleep per night.

Less than 4 hours or greater than 9 hours of sleep is associated with higher
morbidity.

POTENTIAL CAUSES OF SLEEP DISRUPTION IN OLDER PERSONS

Sleep problems in older persons

Personal characteristics

Environmental characteristics

Home environment

A combination of these factors

Medications that disturb sleep

STAGE TYPES OF SLEEP-SELECTED CHARACTERISTICS

Midterm Notes 23
 STAGE 1: Light sleep, easily awakened.

STAGE 2: Medium deep sleep, more relaxed than stage 1, slow eye movements,
fragmentary dreams, easily awakened.

STAGE 3: Medium deep sleep, relaxed muscles, slowed pulse, decreased body
temperature, awakened with moderate stimuli.

STAGE 4: Deep sleep, restorative sleep, body movement rare, awakened with
vigorous stimuli, REM, active sleep, rapid eye movement, increased/fluctuating
pulse, blood pressure, and respirations. Dreaming occurs.

TYPES OF SLEEP DISTURBANCES, EXAMPLES OF MEDICATION

Alteration of REM sleep

Delayed onset of sleep

Nocturnal awakening

Daytime sleepiness

SLEEP DISORDERS AND CONDITIONS

Sleep Apnea - absence of breathing during sleep.

Periodic Limb Movement - sudden limb movements which will lead to awakening;
possibly caused by neurological conditions.

EXACERBATIONS OF SLEEP DISTURBANCES

Behavioral problems

Traffic accidents

Memory lapses

Emotional instability

Decreased daytime functioning

THE RISKS AND BENEFITS OF PHARMACOLOGICAL AND

NONPHARMACOLOGICAL INTERVENTIONS FOR SLEEP
DISTURBANCE
OTC SLEEP AIDS

OTC sleep aids contain antihistamines (diphenhydramine, benadryl) which can

cause daytime sleepiness, dizziness, and blurred visions.

BENZODIAZEPINES

Midterm Notes 24
 Benzodiazepines can exacerbate sleep apnea, suppress deep sleep, increase the
likelihood of falling, and cause increased confusion.

TREATMENTS FOR SLEEP APNEA

Weight reduction

Sleeping on the side rather than the back

Avoiding sleeping pills and alcohol before sleeping

Avoiding smoking

CPAP

Surgery

SLEEP RESTRICTION THERAPY

Using the bed for sleep.

Getting out of bed if unable to fall asleep.

Keeping regular sleep time routines.

Avoiding daytime naps.

HERBAL/NATURAL REMEDIES

Melatonin

Chamomile tea

Valerian root

A small evening snack (natural tryptophan)

APPROPRIATE NURSING INTERVENTIONS TO IMPROVE/RESTORE SLEEP

Individualize nighttime care.

If sleep disturbances are caused by underlying medical problems:

Investigate and treat nighttime pain.

Treat depression and anxiety disorders.

Encourage sleep hygiene.

Correct environmental problems.

Recommed dietary and lifestyle changes.

Encourage daytime activities.

Midterm Notes 25
 Discourage long naps.

NON-ADHERENCE (NONCOMPLIANCE)
RISK FACTORS
▪Living alone without social support.
▪ Visual or auditory impairments.
▪ Increasing use of alcohol.
▪ Socioeconomic factors.
▪ Unpalatable bulk powders or large tablets.

NURSING MANAGEMENTS FOR IMPROVING CLIENT ADHERENCE

If knowledge deficits are a problem, provide verbal education, reinforced with

written instructions and allow time for client’s feedback.

Encourage a client who “pharmacy shops” to have prescriptions filled at the same
pharmacy each time.

Provide and assist remembering to take medications.

Reduce the impact of drug side effects.

➢ Give adequate intake of fiber and fluid to reduce constipation.
➢ Diuretics can be scheduled in the morning to reduce interruptions of activities
and sleep.
➢ Use of Isotonic liquids or sugar-free lozenges can help with dry mouth.

ROLES OF THE NURSE

Being aware of the routes of eliminations of medications and the implication of

aging on these routes.

Being aware of the effects of aging on the typical signs and symptoms of medication
toxicity.

Maintaining knowledge of the signs of medication toxicity in the older adult.

Drawing random, peak and trough medication levels correctly.

Knowing when to notify the prescriber of abnormal results.

Midterm Notes 26
 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

💚 Omission or commission of an act that departs from acceptable and reasonable

standards, which can take several forms:

Malfeasance: committing an unlawful or improper act.

Misfeasance: performing an act improperly.

Nonfeasance: failure to take proper action.

Malpractice: failure to abide by the standards of one’s profession.

Criminal negligence: disregard to protection the safety of another person.

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.

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.

Midterm Notes 27
 9. RECIPROCITY – 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 CONCERNED
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:

Between spouses and the elder’s wishes and interest;

Between family members and the elder’s wishes and interest;

Between a guardian, conservator or other lawfully designated agent and the

elder’s wishes and interests;

Between a caregiver’s business interests and the elder’s interests, well-being,

and quality of life.

2. Perceived Conflicts of Interest: 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.

LEGAL RISKS IN GERONTOLOGICAL NURSING

▪Malpractice
▪ Confidentiality
▪ Patient consent

▪ Patient competency
▪ Staff supervision

Midterm Notes 28
 ▪ Restraints
▪ Telephone orders

▪ Medications
▪ Do not resuscitate orders
▪ Advance directives and issues related to death and dying
▪ Elder abuse

Week 9: Long-Term Care

The long- term care facility is becoming a complex and dynamic clinical setting for
nursing practice.

Increasingly, such facilities are caring for a more medically complex population than
ever before; many nursing homes are establishing subacute care units that provide
ventilator care, hyperalimentations, and other services that were confined to hospital
settings.

Although the number of facilities providing long-term care has declined since the
implementation of tougher standarsds, the number of residents who are served in long-
term care facilities has grown along with the growth of the older people entering their
senior years, a majority will need some type of facility-based or community long-term
care, and about half of all older women and one third of all older men will spend some
time in a long –term care facility during their lives.

Consumers are well informed of the standards of good care and quality living
environments, giving them higher expectations of providers than previously. Also, for
many nurses who have become frustrated with the caregiving limitations of abbreviated
hospital stays and fragmented care, such facilities offer an opportunity to establish long-
term relationships and practice nursing’s healing arts.

Long-term care is a variety of services which help meet both the medical and non-
medical needs of people with a chronic illness or disability who cannot care for
themselves for long periods.

FACILITY-BASED LONG-TERM CARE TODAY

Conditions in nursing homes, now commonly referred to as long-term care facilities,
have improved, largely due to federal regulations and increased professional interest in
this case setting.

Midterm Notes 29
 Licensed staff must be on duty around the clock, nursing assistants must complete a
certification process, the use of chemical and physical restraints has declined, and
documentation has improved. However, problems do remain.

Issues such as insufficiently and inconsistently staffing ang high staff turnover and
conditions such as pressure ulcers, dehydration, and malnutrition continue to plague this
care setting.

NURSING HOME STANDARDS

“Must provide services and activities to attain or maintain the highest practicable
physical, mental, and psychosocial well-being of each resident in accordance with a
written plan of care.”

REGULATIONS RELATED TO NURSING HOMES

▪ Resident rights
▪ Admission, transfer, and discharge rights
▪ Resident behavior and facility practices
▪ Quality of life
▪ Nursing services
▪ Dietary services

▪ Physician services
▪ Specialized rehabilitation services
▪ Dental services
▪ Pharmacy services
▪ Infection control
▪ Physical environment
▪ Administration

NURSING HOME RESIDENTS

Care homes, also called residential care facilities or group homes, are small private
facilities, usually with 20 or fewer residents.

FACTORS TO CONSIDER WHEN SELECTING A NURSING HOME

▪ COST
▪ PHILOSOPHY OF CARE

Midterm Notes 30
 ▪ ADMINISTRATION
▪ SPECIAL SERVICES

▪ STAFF
▪ RESIDENTS
▪ PHYSICAL FACILITY
▪ MEALS
▪ ACTIVITIES
▪ CARE
▪ FAMILY INVOLVEMENT
▪ SPIRITUAL NEEDS

ASSISTED LIVING COMMUNITIES

Designed for older adults who are able to remain independent and active, but need a
helping hand.

MAJOR RESPONSIBILITIES OF GERONTOLOGICAL NURSES IN LONG-

TERM CARE FACILITIES
▪ Assist residents and their families in the selection of and adjustment to the facility.
▪ Assess and develop an individualized care plan based on assessment data.
▪ Monitor residents’ health status.
▪ Recommend and use rehabilitative and restorative care techniques when possible.
▪ Evaluate the effectiveness and appropriateness of care.

▪ Identify changes in residents’ conditions and take appropriate action.

▪ Communicate and coordinate care with the interdisciplinary team.
▪ Protect and advocate for residents’ right.
▪ Promote a high quality of life for residents.
▪ Assure residents’ preferences and choices are honored.
▪ Ensure and promote the competency of nursing staff.

PALLIATIVE CARE
It is an interdisciplinary medical caregiving approach aimed at optimizing quality of
life and mitigating suffering among people with serious, complex illness.

Midterm Notes 31
 Palliative care is the active total care of clients whose diseases is not responsive to
curative treatment.

Control of pain, of other symptoms, and of psychological, social, and spiritual

problems is paramount.

The goal of palliative care is achievement of the best possible quality of life for
clients and family. It affirms life and regards dying as a normal process.

4 MAIN GOALS OF PALLIATIVE CARE

1. Pain control

2. Managing other symptoms (n/v, loss of appetite, DOB)

3. Helping emotional needs

4. Support for caregiver

HOSPICE
A way of caring for terminally ill individual and their families. Although most
hospice care is provided in the home, these services are required to be provided in
nursing home settings also.

The first hospice program was St. Christophers’ Hospice in London. In the United
States, the first hospice began at Hospice, Inc. in New Haven, Connecticut, in 1974.

The National Hospice Organization has developed standards for hospice care to
guide local hospice programs; however, individuality and autonomy of each program
are encouraged.

Hospice care aids in adding quality and meaning into the remaining period of life.
The care involves interdisciplinary efforts to address physical, emotional, and
spiritualneeds, including:

pain relief

symptom control

coordinated home care and institutional care

bereavement follow-up and counseling

ADVANCE MEDICAL DIRECTIVES

Permit people to set forth in writing their wishes and preferences regarding
healthcare.

Midterm Notes 32
 Use to indicate the patient’s decisions if the time should come when they are unable
to speak for themselves.

Is not operative until the patient is no longer capable of making 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

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.

Perceived Loss

Loss that is less tangible & uniquely defined by the grieving client (loss of
confidence, prestige).

Experienced by one person but cannot be verified by others.

Subjective.

Maturational Loss

Change in developmental process that is normally expected during a lifetime.

Loss that occur on the process of normal development.

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.

Any sudden, unexpected and definable event that is not predictable.

Actual Loss

Midterm Notes 33
 Can be identified by others & can arise either in response to or in anticipation of
a situation.

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

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.

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.

Dysfuntional Grief

Occurs when there is prolonged emotional instability, withdrawal from usual

task oractivities that previously gave pleasure & lack of progression from one
level to successful coping with the loss.

Extended grief, unsuccessful use of intellectual and emotional responses by

which individuals attempt to work through the process of modification.

Dysfunctional Grief may be:

Midterm Notes 34
 (1) Unresolved Grief - extended in length and severity, bereaved may also have
difficulty expressing the grief, may deny the loss or may grief beyond expected
time; severe chronic grief reaction in which the person does not complete the
resolution stage of the grieving process within a reasonable time.
(2) Inhibited Grief – many of normal symptoms of grief are suppressed and
other effects, including somatic are experienced instead.

GRIEVING PROCESS

Sequence of affective, cognitive & physiological states through which the person
responds to and finally accepts an irretrievable loss.

Bereavement

The subjective response experienced by the surviving loved ones after the death
of a person with whom they have shared a significant relationship.

Experience alterations in libido, concentration, patterns of eating, sleeping,

activity and communication.

CONCEPTS WHICH HELP NURSE TO PLAN FOR

INTERVENTIONS
MOURNING

The behavioral process through which grief is eventually resolved or altered.

Process by which people adapt to a loss which is influenced by cultural, customs,

rituals, and society’s rules for coping with loss.

HOPE

Characterized by a confident, yet uncertain expectation of achieving a goal.

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.).

Midterm Notes 35
 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.

Concern is not about death itself but about pain and loss of control, fear of
separation, abandonment, loneliness or mutilation.

SIGNS OF IMPENDING DEATH

LOSS OF MUSCLE TONE
a. Relaxation of the facial muscles (jaw may sag).
b. Difficulty speaking.
c. Difficulty swallowing & gradual loss of the gag reflex.
d. Decreased activity of the GIT, with subsequent nausea, accumulation of flatus,
abdominal distention, & retention of feces.
e. Possible urinary & rectal incontinence due to decreased sphincter control.
f. Diminished body movement.

SLOWING OF THE CIRCULATION

a. Diminished sensation.
b. Mottling & cyanosis of the extremities.
c. Cold skin, first in the feet and later in the hands, ears and nose (however the client may
feel warn due to elevated temperature).

CHANGES IN VITAL SIGNS

a. Decelerated and weaker pulse.
b. Decreased BP.
c. Rapid shallow, irregular, or abnormally slow respirations; Cheyne strokes respirations;
noisy breathing, referred to as death rattle due to collecting of mucus in the throat; mouth
breathing, which leads to dry oral mucus membranes.

SENSORY IMPAIRMENT

Midterm Notes 36
 a. Blurred vision.

b. Impaired sense of taste & smell (hearing is the last sense to disappear.

CLINICAL SIGNS OF DEATH

Cessation of the apical pulse, respirations and blood pressure.

Total lack of response to external stimuli.

No muscular movement, especially breathing.

No reflexes.

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 & CARE OF THE BODY

RIGOR MORTIS

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.

Starts in the involuntary muscles (heart,bladder, etc.) then progresses to head, neck,
trunk and finally reaches the extremities.

Leaves the body about 96 hours after death.

ALGOR MORTIS

Gradual decrease of the body’s temperature after death.

When blood circulation terminates and the hypothalamus ceases to function, body
temperature falls about 1 degree Celsius per hour until it reaches room temperature.

LIVOR MORTIS

Bluish discoloration of the skin after death.

After blood circulation has ceased, skin becomes discolored.

Midterm Notes 37
 The RBC breakdown, releasing hemoglobin, which discolors the surrounding
tissues.

EMBALMING

Injection of chemicals in the body to destroy the bacteria.

Tissues after death become soft & eventually liquefied by bacterial fermentation.

The hotter the temperature, the more rapid the change, therefore, bodies are often
stored in cool places to delay the process.

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 head 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 and oozing feces or
urine.

8. Remove all jewelries and present it and any valuables to the family.

9. If the wedding band is left in place, tape it securely to the finger.

10. Allow family members to enter the room when body is prepared and 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 ankle 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 filed in
a local health or other government office.

Midterm Notes 38
 Family is given a copy to use for legal matters.

LABELING OF THE DECEASED

If appropriately identified and prepared incorrectly, this can create legal problems.

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
Terminally Ill Client: 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.

Midterm Notes 39
 Terminally Ill Client: 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

Support client in his expression of the philosophy he has chosen for his life.

Attentive listening encourages client to express feelings, clarify them, and accept his
fate.

Praying silently with the client.

Make referral for spiritual counseling.

Facilitate expression of feeling, prayer, meditation, reading, and discussion with

appropriate clergy/spiritual advisor.

CARING FOR TERMINALLY ILL PATIENT

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.

Ask the patient what he needs or what would make him more comfortable. Perhaps
this is music, special books or a visit from a certain person. Try to meet any requests
the patient has. If a request is not possible to fill, ask the patient if there is anything
else you can do as a substitute.

Arrange to help the immediate family. Perhaps the spouse could benefit from having
meals prepared and brought to him so he can be at his wife's bedside. Child care
might be needed. Reducing stress from the patient's loved ones can also reduce the
cancer victim's stress.

Offer to record messages for the patient. Some patients might wish to leave a video
message for young children, unborn grandchildren or others, which could be nothing
more than a legacy of who he is.

Be present. If your friend or loved one is afraid to die, be there for her. If you can't be
present, arrange for others to sit with her through her fear. You can only do so much
and be there so much, but your presence or the presence of another person can be
very comforting to a terminally ill cancer patient.

Incorporate things the patient likes into visits. If the patient loves flowers, bring in
fresh flowers for a visit. If the patient loves a certain cookie, bring this if it's allowed.
If the patient loves to read but no longer can, bring a book on CD for her to listen to.

Midterm Notes 40
 Offer comfort and as much understanding as possible. Don't pretend to understand
what the patient is going through. You haven't died, and left loved ones so you don't
know what it is like to face certain death. Hugs and even holding a hand might bring
the patient much comfort.

ETHICAL DILEMMAS FACING GERONTOLOGICAL

NURSING
Nursing practice involves many situations that could produce conflicts-conflicts between
nurses’ values and external systems affecting their decisions and conflicts between the
rights of patients and nurses responsibilities to those patients.

It is easy to say that nurses should always follow the regulations, adhere to principles,
and do what is best for the patient.

ISSUES ON CONFLICT OF INTEREST

Actual Conflict of Interest - issues between family members and caregivers

represent the elderly or assist them in decision-making. These include conflicts:
➢ Between spouses and the elder’s wishes and interest;
➢ Between family members and the elder’s wishes and interest;
➢ Between a guardian, conservator or other lawfully designated agent and the
elder’s wishes and interests;

➢ Between a caregiver’s business interests and the elder’s interests. Well-being and
quality of life.

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.

EXPANDED ROLE OF NURSES

Midterm Notes 41
 The wider scope of functions, combined with higher salaries and greater status, has
increased the accountability and responsibility of nurses for the care of the patients.

MEDICAL TECHNOLOGY

Artificial organs, genetic screening, new drugs, computers lasers, ultrasound, and
other innovations have increased the medical community’s ability to diagnose and
treat problems and to save lives that once would have been given no hope. However,
new problems have accompanied these advances, such as determining on whom,
when, and how this technology should be used.

GREATER NUMBER OF OLDER ADULTS

Entitlement programs and services for older persons had less impact when a small
portion of the population was old, but with growing numbers of people spending
more years in old age and the increasing ratio of dependent individuals to productive
workers, society is beginning to feel burdened.

ASSISTED SUICIDE

The ANA has been clear in its objection to assisted suicide, believing instead that
nurses should provide competent, compassionate end of life care. However, although
participating in a patient’s assisted suicide is unethical and inappropriate, nurses may
care for terminally ill individuals who becomes even more complicated by the fact
that laws have been enacted (e.g. Oregon’s death with dignity Act of 1997) to allow
terminally ill persons to end their lives with lethal medications, and individuals have
the right to refuse care under self-determination directives.

Week 10:

Midterm Notes 42