CARE OF THE CHRONICALLY ILL

AND THE OLDER ADULT

Gerontological Nursing Concepts,
Standards of Care
• Quality of Care: The gerontological nurse
systematically evaluates the quality of care and
effectiveness of nursing practice
• Performance Appraisal: The gerontological nurse
evaluates his or her own nursing practice in
relation to professional practice standards and
relevant statues and regulation
• Education: The gerontological nurse acquires and
maintains current knowledge applicable to
nursing practice
• Collegiality: The gerontological nurse contributes
to the professional development of peers,
colleagues, and others
• Ethics: The gerontological nurse’s decisions and
actions on behalf of older adult are determined
in an ethical manner
• Collaboration: The gerontological nurse
collaborates with the older adult, the older
adult’s caregiver, and all members
• Research: The gerontological nurse interprets,
applies, and evaluates research findings to
inform and improve gerontological nursing
practice
• Resource Utilization: The gerontological nurse
considers factors related to safety, effectiveness,
and cost in planning and delivering patient care
 Ethical Aspects in the
care of the older person
• Ethical Issues Commonly Addressed in
Gerontological Nursing
• Values clarification is a tool that nurses
can use as they address ethical issues in
everyday care of older adults
• Nurses are often involved in decisions
about artificial hydration & nutrition
• Assisting with care decisions during
chronic illness is one of the most
challenging aspects of nursing
 Cultural Aspects of
Legal & Ethical Issues
• Language barriers are important to consider when
discussing advance directives
• Nurses should identify culturally influenced patterns
of decision making when discussing advance
directives and end-of-life care patients and their
families
Role of Nurses Regarding Legal & Ethical Issues
• Nurses communicate with older adults about advance
directives, inform other members of the health care
team, and address barriers in implementation
• Nurses facilitate decision making about advance
directives by providing information and care options
to older adults and proxy decision makers
 Bioethical Components of
Care in Older Adult
• Autonomy
– It's common for geriatric patients to arrive in
the ER, or the nursing home, no longer
mentally capable of making those judgments.
At this point, it becomes important to
determine what their wishes are, or would
have been.
 Bioethical Components of
Care in Older Adult
• Beneficence & Non Maleficence
– The charge to do good, and to "first, do no harm," comes naturally.
– Elder care, however, can challenge these seemingly simple
directives. When a patient in the final stages of dementia requires a
feeding tube, for example, the person giving care might wonder if it
is kinder to go through the insertion procedure and prolong life, or
to simply let nature take its course.
– Elderly men and women who seem to function tolerably well at
home can quickly deteriorate in a nursing home or other long-term
care setting. The question is whether they should be allowed to stay
at home if they have fallen or are often forgetful. For geriatric
patients, the line between helping and harming can be thin.
 Bioethical Components of
Care in Older Adult
• Justice
– This ethical principle, which deals with health care
as a resource, sometimes seems like a subject for
theoretical debate.
– Should medical care be made available to those
whom it most benefits, or to those who need it
most? Note that the two positions are not the
same. In the first, "utilitarian" view, health care
would be skewed toward those who are most likely
to recover, whereas in the second, "idealistic"
stance, it would go to those in dire need, regardless
of whether or not it would save them.
Wellness
• Nutrition support
– Elderly prefer Familiar foods that looks appetizing
and delicious
– To avoid any food playing offer one dish at a time
– Cut foods into smaller pieces
– Liquids may be easier to swallow if converted to
gelatin
– Hot foods or beverages should be offered warm,
and must be checked to prevent burns
– As deficits progress feeding might be necessary
– Forgetfulness, disinterest, dental problems and
choking may all serve as a barrier
Wellness
• Stress Management
– Despite profound cognitive losses, patients
are sometimes aware of their diminishing
abilities needing constant emotional support
that reinforces positive self image
– Goals are adjusted to fit elders ability
– Environment should be kept familiar and
noise free
– Becoming familiar with particular elder’s
predicted responses to certain stressors helps
care givers avoid similar situation
Wellness
• Activity & Exercise
– Caregivers must identify the needs to be able to
assist well
– Adequate sleep and physical exercise are essential
– If sleep is interrupted or cannot sleep, music,
warm milk, or a back rub may help the patient to
relax
– During the day they should be encouraged to
participate in exercise because a regular pattern
of activity and rest enhances night time sleep
– Long periods of sleep are discouraged
Physiologic Functioning
• Activity & Exercise
– The same as in Wellness: Activity & Exercises
• Nutrition Support
– The same as in Wellness: Nutrition Support
• Respiratory Management
– Stop smoking, because it is the single most important preventable
cause of disease
– Pneumonia & Influenza Vaccinations and prevention of
environmental tobacco smoke and crowded places during flu
season
– Prevent Respiratory infections by proper hygienic measures such as
hand washing
– Techniques such as Deep Breathing, and HOB elevation are also
management for respiratory difficulties or disorders
Physiologic Functioning
• Tissue Perfusion Management
– Specifics are addressed to risk
factors such as hypertension,
smoking, obesity and lipid disorders
as well as preventive measures like
stress reduction, healthy dietary
pattern and most of the time
medical or pharmacologic
intervention
Physiologic Functioning
• Electrolyte & Acid – Base Balance Management
– Ensure adequate fluid intake or hydration at 1500-2500 mL per
day in the absence of disorders like heart failure
– The fluid intake recommendation should be tailored for the
elders and provides basic suggestion only
– Though it is not known why nocturia increases with old age, it
has been suggested that GFR and clearance of electrolytes
decreases with standing and is enhanced with horizontal
positioning
– Nocturia and urinary incontinence may cause the elderly to
voluntarily restrict their fluid intake. Holding fluids 2 hours
before bedtime may help decrease the frequency of nocturia
and nighttime incontinence.
– Provide ventilation through fans, drape windows from direct
sunlight, and use air conditioning to assist with controlling
fluid loss from excessive room temperature.
Physiologic Functioning
• Bathing: Skin should be cleaned with mild soap and warm
water and gently patted dry. Or a no-rinse cleanser can be
used.
• Protecting skin: Skin that is vulnerable to excess moisture
can be protected with talcum powder. Dry skin should have
lotion applied.
• Inspecting skin: Daily skin inspection is important for
identifying vulnerable areas of skin or early signs of
pressure sores.
• Managing incontinence: Urinary or bowel incontinence
should be managed to prevent moisture and bacterial
exposure to skin. Care may include frequently scheduled
assistance with urinating, frequent diaper changes,
protective lotions on healthy skin, urinary catheters or
rectal tubes.
Physiologic Functioning
• Cleaning: It's essential to keep wounds clean to
prevent infection. A stage I wound can be gently
washed with water and mild soap, but open sores are
cleaned with saline solution each time the dressing is
changed.
• Dressings: A dressing promotes healing by keeping a
wound moist, creating a barrier against infection and
keeping the surrounding skin dry. A variety of
dressings are available, including films, gauzes, gels,
foams and various treated coverings.
Physiologic Functioning
• Pain management: Interventions that may reduce
pain include the use of nonsteroidal anti-
inflammatory drugs — such as ibuprofen (Motrin,
Advil, others) and naproxen (Aleve, others) —
particularly before and after repositioning,
debridement procedures and dressing changes.

• Antibiotics: Pressure sores that are infected and don't

respond to other interventions may be treated with
topical or oral antibiotics.
Physiologic Functioning
• Physical Comfort Promotion
– Repositioning in a wheelchair:
• Frequency: As much as possible on their own every 15
minutes and should have assistance with every hour
• Cushions: includes foam, gel, and water filled – which can
relieve pressure and help ensure that the body is
appropriately positioned in the chair
– Repositioning in Bed:
• Frequency: At least every2 hours
• Bed Elevation: HOB should be raised at no more than 30°
• Bony areas can be protected with proper functioning and
cushioning, rather than lying directly on a hip it’s best to
lie at an angle with cushions supporting the back or front.
 Behavioral
• Coping Assistance
– Assisting older persons to identify stressors and rate their
levels of stress
– Educating the older person and family about stress theory and
the stress cycle
– Helping the older person identify successful coping mechanism
used in the past during periods of high stress
– Assisting the older person to examine current coping
mechanisms and behaviors and alter or eliminate negative or
maladaptive mechanisms
– Reinforcing and strengthening positive coping mechanisms
– Investigating community resources, support groups, stress-
reduction clinics, and other stress relievers that may be useful
to the older person.
Behavioral
Behavioral
• Patient Education
– Focus should be enhancing self esteem: improving
functioning, using verbal and non verbal
communication,
– Promote sense of control: providing information,
rephrasing events, addressing threats such as lack of
privacy and loss of individuality
– Involve them in decision making: challenging attitudes,
facilitating communication
– Encourage life review & reminiscence
• Spiritual Care
– Communicating, caring and compassion, instilling hope,
referring for spiritual care, encouraging participation in
religious activities
Refusal to take medication
Safety
• Risk reduction activities
– For all older adults, risk reduction intervention
involves lifestyle , such as weight management,
optimal nutrition, adequate physical activity,
sufficient sleep and stress relieving techniques
– It may also include OTC medications, nutritional
supplements, complementary and alternative
therapies
– Vaccinations
• Management of the Environment
– Modifying the environment to decrease falls and
injuries but familiarity for them should be
considered
Community resources for care of
older persons (DOH programs)
• Senior Citizens Act 9257
– Expanded Senior Citizens Act of 2003, an act
granting additional benefits and privileges to
senior citizens
– Amending for the purpose Republic Act No. 7432,
otherwise known as "An act to maximize the
contribution of senior citizens to nation building,
grant benefits and special privileges and for other
purposes
– provided for the expansion of coverage of
benefits and privileges that the elderly may
acquire, including medically necessary services.
 Community resources for care of
older persons (DOH programs)
• Republic Act No. 9994
– Expanded Senior Citizens Act of 2010, an act granting additional
benefits and privileges to senior citizens, further amending Republic
Act No. 7432, as amended, otherwise known as "An act to maximize
the contribution of senior citizens to nation building, grant benefits and
special privileges and for other purposes"
– One of the provisions of RA 9994 or the Expanded Senior Citizens act
of 2010 is for the DOH to administer free vaccination against the
influenza virus and pneumococcal diseases for indigent senior citizens.
– The DOH in coordination with local government units (LGUs), NGOs and
POs for senior citizens shall institute a national health program and
shall provide an integrated health service for senior citizens.
– It shall train community – based health workers among senior citizens
health personnel to specialize in the geriatric care and health problems
of senior citizens.
Community resources for care of
older persons (DOH programs)
• Republic Act No. 7876
– Senior Citizens Center Act of the Philippines,
an act establishing a senior citizens center in
all cities and municipalities of the Philippines,
and appropriating funds therefore.
– House Bill No. 834
– Centenarians Act of 2010, grant 50 percent
discount and value-added tax (VAT)
exemption on goods and services for Filipino
citizens who reach the age of 100 years and
above.