CONTENTS

I. PRELIM COVERAGE
• Overview of Gerontologic Nursing
• Theories of Aging
• Legal & Ethical Issues
• Comprehensive Gerontologic Assessment
• Influences on Health & Illness
II. MIDTERM
• Wellness issues
• Common psychologic /Psychophysiological stressors & disorder among
elderly
o 1.Anxiety
o 2. Depression
o 3. Suicide
o 4. Mental Retardation
o 5. Pain
o 6. Infection
o 7.Substance Abuse
o 8. Cancer
o 9. Loss & end of life issues
III. SEMI FINAL
• Nursing Care Of Physiologic & Psychologic Disorders
• Cardiovascular Function
o Hypertension
o Coronary Artery Disease
o Arrhytmia
o Syncope
o Congestive heart Failure
o Peripheral Artery Occlusive Disease
o Anemia
• Respiratory Function Obstructive Pulmonary disease
o Tubeculosis
o Pneumonia
• Endocrine Function
o Diabetes
o Hperthyroidism
o Hypothyroidism
• Gastrointestinal Function
o Dysphagia
o Gastroesophageal reflux
o Ulcers
o Intestinal Obstruction
o Polyps
o Cirrhosis
o Colorectal Cancer
o Cholelithiasis/cholecystitis
IV. FINALS
• Musculoskeletal Function
o Hip Fracture
o Arthritis
o Osteoporosis
 o Foot problems
- Corn
- Calluses
- Bunions
- Hammertoe
- Nail disorders
• Urinary Function
o Acute & Chronic Incontinence
o Renal Failure
o Urinary Tract Infection
o Benign Prostatic hypertrophy
• Cognitive & Neurologic Function
o Delirium & Dementia
o Parkinson’s Disease
o Cerebrovascular Attack
• Integumentary Function
o Common skin growth
o Melanoma
o Ulcer
• Sensory Function
o Cataract
o Glaucoma
o Cataract
o Dysequilibrium
o Hearing loss
o Changes in sense of smell and taste

PRELIM COVERAGE

Specific Instructions in the completion of each Chapter:

1. Set your learning goals. Read and understand the Intended Learning
Outcomes of each chapter. This shall serve as your checklist of acquired
knowledge and skills after completing the entire chapter, likewise, the basis
 of the teacher in the formulation of the summative evaluation given at the
end of each chapter.
2. Lecture notes are provided for you. BE SURE NOT TO SKIP the lecture. Read
and understand before answering the activities. You can take note those
concepts that are not clear to you and refer to your subject teacher during
the specified consultation hours.
3. Read the teacher’s insight and open video links provided to supplement the
lecture notes.
4. As you go on, you will encounter exercises that will test your knowledge and
understanding as well as your critical thinking. Read the instructions carefully,
and write your answers to the space provided at the end of each chapter.
5. Compile your outputs in your Learning Portfolio to be submitted on the date
set by your teacher.
6. Should you have any queries or clarifications with the topics, please contact
your subject teacher during consultation hours (please refer to the
preliminaries of this material).

CHAPTER 1 : History and Evolution

Duration: ________

INTENDED LEARNING OUTCOMES:

• After the designed activities, the student will be able to:
1. Enhance their understanding in concepts about History and
Evolution of Care in Older person
2. Heighten students familiarity in the different Theories in Aging and
various ethical issues relevant to Care of elderly.
3. Improve their Health Assessment skills in Older person.
4. Fully appreciate the concepts in different factor influence the health
and illness of an older person.

SPECIFIC ACTIVITIES:
1. Reading and comprehension of the concept.
2. Critical Thinking Exercises:
• Case Analysis
• Multiple Choice type of Examination

Historically, societies have viewed their elder members in a variety of ways.

• TIME OF CONFUCIUS-there was a direct correlation between a person’s age

and the degree of respect to which he or she was entitled.
• EARLY EGYPTIANS -dreaded growing old and experimented with a variety of
potions and schemes to maintain their youth.
• EARLY GREEKS:
-PLATO- promoted older adults as society’s best leaders.
-ARISTOTLE -denied older people any role in governmental matters.
• ROMAN EMPIRE- the sick and aged were customarily the first to be killed.
• CHRISTIANS - the Bible is God’s concern for the well-being of the family and
desire for people to respect elders (Honor your father and your mother …
Exodus 20:12). Yet, the honor bestowed on older adults was not sustained.
 • MEDIEVAL TIMES - gave rise to strong feelings regarding the superiority of
youth; these feelings were expressed in uprisings of sons against fathers.
• ENGLAND- developed Poor Laws in the early 17th century that provided care
for the destitute and enabled older persons without family resources to have
some modest safety net.
-No labor laws protected persons of advanced age; those unable to meet the
demands of industrial work settings were placed at the mercy of their
offspring or forced to beg on the streets for sustenance.
• Between 1900 & 1940- Burnside found 23 writings including the works of
Lavina Dock, with a focus on older adults and covering such topics as rural
nursing, almshouses and private duty nursing, as well as early case studies
and clinical issues addressing home care.
- He also discovered an anonymous column in AJN entitled “Care of the
Aged” that was written in 1925, one of the earliest references to the need
for a specialty in older adult care.
- 1988- Conducted an extensive review of the American Journal of Nursing
(AJN) for historic materials related to gerontologic nursing
• AMERICA - significant step in improving the lives of older Americans was the
passage of the Federal Old Age Insurance Law under the Social Security Act
in 1935, which provided some financial security for older persons
- The profound “graying” of the population started to be realized in the
1960s, and the - -United States responded with the formation of the
Administration on Aging, enactment of the Older Americans Act, and the
introduction of Medicaid and Medicare, all in 1965.
• 1962-geriatric nursing conference group was established during the American
Nurses Association (ANA) convention.
• 1966- ANA established the division of Geriratric Nursing Practice and defined
geriatric nursing as “ concerned with the assessment of nursing needs of
older people; planning and implementing nursing care to meet those needs;
and evaluating effectiveness of such care”
• 1976-the Division of Geriatric Nursing was changed to the division of
Gerontologic Nursing Practice to reflect the nursing roles of providing care to
healthy, ill and frail older person.
• 1984- the division became the council of Gerontologic Nursing to encompass
issues beyond clinical practice.
DEVELOPMENT OF GERONTOLOGIC NURSING:1960-1970
YEAR EVENT
1961 Formation of specialty group for geriatric nurses is recommended by ANA.
1962 First National meeting of the ANA Conference on Geriatric Nursing Practice
, American Nurse’s Foundation receives a grant for a workshop on the
aged.
First research in geriatric nursing is published in England (Norton D et al:
An investigation of geriatric nursing problems in hospital, London 1962,
National Corporation for the Care of Old People).
1966 First gerontologic clinical specialist nursing program is developed at Duke
University by Virginia Stone.
Geriatric Nursing Division of the ANA is formed; a monograph is published,
entitled Exploring Progress in Geriatric Nursing Practice.
1968 Laurie Gunter is the first nurse to present a paper at the International
Congress of Gerontology in Washington D.C.
First gerontologic nursing interest group, Geriatric Nursing is formed.
1970 Standard of geriatric nursing practice is first established.
 First gerontological clinical nurse specialist graduate from Duke University.

TERMINOLOGY:
Geriatrics – from the Greek geras, meaning “old age”
- is the branch of medicine that deals with the diseases and problems of old
age.
Gerontology – from the Greek geron, meaning “old man”
- the scientific study of the process of aging and the problems of aged
persons; it includes biologic, sociologic, psychologic, and economic aspects
Gerontologic nursing – this specialty of nursing involves assessing the health and
functional status of the older adults, planning and implementing health care and
services to meet the identified needs , and evaluating the effectiveness of such care
- is the term most often used by nurses specializing in this field.

IMPACT OF AN AGING ADULT POPULATION ON GERONTOLOGIC NURSING

The development of gerontologic nursing as a legitimate specialty, the current
challenges are:
1. Solidify the specialty as a major force within the health care arena
2. Participate in the development of an appropriate health care delivery
framework for older adults that consider their unique needs

NURSING PRACTICE – older adult health consumer are more knowledgeable and
discerning and thus are better informed as they become more active decision makers
about their health and well being. Because they have greater privilege than they had
in the past.
- Older adults are demanding more programs and services aimed at health
maintenance and promotion and disease and disability prevention.
- Gerontologic nurses will play an integral role in affecting changes in the
various emerging practice arenas. They will practice in clinics, home care
environment and older adult living in the communities that range from
independent homes to rehabilitation centers.
- Gerontologic nurses must continue to educate older persons about their
care options and lobby for legislation.
NURSING EDUCATION – in America according Alford (1987) between 1980 and 2030
the estimated number of RNs needed to care older adults will increase by 466%

ROLE OF NURSES:
Guide persons of all ages toward a healthy aging process.
Eliminate ageism.
Respect the rights of older adults and ensure others do the same.
Oversee and promote the quality of service delivery.
Notice and reduce risks to health and well-being.
Teach and support caregivers.
Open channels for continued growth.
Listen and support.
Offer optimism, encouragement, and hope.
Generate, support, use, disseminate, and participate in research.
Implement restorative and rehabilitative measures.
Coordinate and manage care.
Assess, plan, implement, and evaluate care in an individualized, holistic manner.
Link services with needs.
Nurture future gerontological nurses for advancement of the specialty.

THE OLDER POPULATION

Butler (1975) offers the following on why age 65 is the discretionary cut off for
defining old age:
-Society has arbitrarily chosen ages 60 to 65 as the beginning of late life primarily
for the purpose of determining a point for retirement and eligibility for services and
financial entitlements for the elderly.
Older client – a being with richly diverse and unique array of internal and external
variables that ultimately influence how the person thinks and acts.

-Older adults are generally defined as individuals aged 65 years and older. At one
time, all persons over 65 years of age were grouped together under the category of
“old.” Now it is recognized that much diversity exists among different age groups in
late life, and older individuals can be further categorized as follows:
young-old: 65 to 74 years
old: 75 to 84 years
oldest-old: 85+

FUNCTIONAL AGE -the years a person has lived since birth

-to describe physical, psychological, and social function; this is relevant in
that how older adults feel and function may be more indicative of their needs
than their chronological age.
PERCEIVED AGE- is another term that is used to describe how people estimate a
person’s age based on appearance.
-Studies have shown a correlation between perceived age and health, in
addition to how others treated older adults based on perceived age and the
resultant health of those older adults (Sutin, Stephan, Carretta, &
Terracciano, 2014).

FACTORS AFFECTING THE INCREASE OF OLDER ADULT POPULATION

o Reduced infant and child mortality as a result of improved sanitation
o Advances in vaccination
o And development of antibiotics
o Large influx of immigrants

ADVANCING AGE IS ASSOCIATED WITH:

o Increased incidence of chronic disease
o Greater vulnerability to illness and injury
o Diminished physical functioning
o Increased likelihood of developing cognitive impairment

CHAPTER 2: THEORIES OF AGING

Theories function is to help make sense of a particular phenomenon; they provide

sense of order and give perspective from which to view facts.

BIOLOGIC THEORY OF AGING

-Concerned with answering basic questions regarding physiologic process that occur
in all living organisms as they chronologically age.
- these theories generally view aging as occurring from molecular, cellular or even a
system point of view
- the foci of biologic theories include explanations of the following:
1. Deleterious effects leading to decreasing function of the organism
2. Gradually occurring age related changes that are progressive over
time
3. Intrinsic changes that can affect all members of a species because
of chronologic age.

2 DIVISIONS OF BIOLOGIC THEORY:

A. STOCHASTIC THEORY – aging as an event that occur randomly and accumulate
over time. The more it is used the more it will age in time.
B. NONSTOCHASTIC THEORY -view aging as certain predetermined, time
phenomena. Regardless of it is used the body will still age. You cannot prevent
aging.

A. STOCHASTIC THEORIES:
1. ERROR THEORY – 1963 called “Error Catastrophe Theory” this idea is based that
errors can occur in the transcription of the synthesis of DNA. These errors are
perpetuated and eventually lead to system that do not function at the optimum level.
The organism’s aging and death are attributable to these events
2. FREE RADICAL THEORY – free radicals are byproducts of metabolism can increase
as a result of environmental pollutants. When these byproducts accumulate, they
damage the cell membrane, which decreases its efficiency. The body produces
antioxidants that scavenge the free radicals.
3. CROSS LINKAGE THEORY -with age according to this theory some proteins in the
body become cross linked. This does not allow for normal metabolic activities and
waste products accumulate in the cell. The end result is that tissues do not function
at optimum efficiency. The proper diet and nutrition can prevent it. Diabetes mellitus,
renal failure.
4. WEAR & TEAR- 1882 equates human with machines. It hypothesizes that aging is
the result of use.

B. NONSTOCHASTIC THEORIES:
1. PROGRAMMED THEORY – normal cells divide a limited number of times; therefore
they hypothesized that life expectancy was programmed. Ex. Menopausal
2. IMMUNITY THEORY- age related functional diminution of the immune system.
Changes occur in the immune system, specifically in the T Lymphocytes, as a result
of aging. These changes leave the individual more vulnerable to disease. Cancers

EMERGING THEORIES (BIOLOGIC THEORY)

A. NEUROENDOCRINE CONTROL OR PACEMAKER THEORY

- neuroendocrine systems controls many essential activities with regard to
growth and development. Scientist are studying the roles that the
hypothalamus and the hormones DHEA (dehydroepiandrosterone) &
melatonin play in the aging process.
- neurologic and endocrine systems
B. METABOLIC THEORY OF AGING/CALORIC RESTRICTION
-the role of metabolism in the aging process is being investigated
 - all organism have a finite metabolic lifetime and that organisms with higher
metabolic rate have a shorter life span.
- Rodent-based research. Caloric restriction increases the lifespan and delays
the onset of age dependent diseases
C. DNA RELATED RESEARCH
- two developments are occurring at this time in relationship to DNA and the
aging process. First, as scientist continue to map the human genome, they
are identifying certain genes that play a role in the aging process.
- Second is the discovery of the telemores, located at the ends of
chromosomes, which may function as biologic clock.

PSYCHOLOGIC THEORIES
- Development does not end when a person reaches adulthood, but
remains dynamic process throughout the life span.
- Influence by both biology and sociology
- Includes behavior changes but also developmental aspects related to the
lives of older adult

A. MASLOW’S HIERARCHY OF HUMAN NEEDS

- Human motivation is viewed as hierarchy of needs that are critical to the
growth and development of all people.
-1954
- SELF-ACTUALIZATION
- Individuals are viewed as active participants in life, striving for self-
actualization.

B. JUNG’S THEORY OF INDIVIDUALISM

- development is viewed as occurring throughout adulthood, with self
realization as the goal of personality development.
- Carl Jung 1960
- SELF- REALIZATION is the goal of personality development, transforming
into a more spiritual being
-as an individual ages he or she is capable of transforming onto a more
spiritual being.
C. ERIKSON’S 8 STAGES OF LIFE
- all people experience eight psychosocial stage during the course of lifetime.
-Individual always have within themselves an opportunity to rework a
previous psychosocial stage into a more successful outcome
- 1993
- 45 to 65, generativity versus self-absorption or stagnation
-65 to death, ego integrity vs despair
D. PECK’S EXPANSION OF ERIKSON’S THEORY
-seven developmental task are identified as occurring during Erikson’s final
two stages.
- Final three of these developmental tasks identified for old age are:
o Ego differentiation vs body preoccupation
o Body transcendence vs body preoccupation
o Ego transcendence vs ego preoccupation
E. SELECTIVE OPTIMIZATION WITH COMPENSATION
- physical capacity diminishes with age
- an individual who ages successfully compensates for these deficits through
selection ( increasing restriction of one’s life to fewer domains of functioning),
 optimization ( people engage in behaviors to enrich their lives) and
compensation ( developing suitable, alternative adaptations).
-Baltes 1987
-

SOCIOLOGIC THEORIES
- Focus on changing roles and relationships
- Relate to the social adaptions in the lives of older adults.

A. DISENGAGEMENT THEORY
- aging as a developmental task in and itself, with its own norms and
appropriate patterns of behavior.
-individual would change from being centered on society and interacting in
the community of being self-centered persons withdrawing from society, by
virtue of becoming old.
B. ACTIVITY THEORY OR DEVELOPMETAL TASK THEORY
- sees activity as necessary to maintain a person’s life satisfaction and
positive self-concept
- Based on 3 assumptions:
o It is better to active than inactive
o It is better to be happy than unhappy
o An older individual is the best judge of his or her own success in
achieving the first two assumptions.
C. CONTINUTIY THEORY
- being active, trying to maintain a sense of being middle aged or willingly
withdrawing from society does not necessarily bring happiness.
- how a person has been throughout life is how that person will continue to
be remainder of life
-the later part of life is continuation of early part of life
-it proposes that as people age, they try to maintain or continue previous
habits, that have contributed to their personalities.
- old age is not a separate phase of life
D. AGE STRATIFICATION
- aging person is an individual element of the society and also a member,
with peers interacting in a social process.
- society consists of groups of cohorts that age collectively
- 5 major concepts of the theory:
o Each individual progress through society in groups of cohorts that are
collectively aging socially, biologically, and psychologically
o New cohorts are continually being born and each of them experiences
their own unique sense of history
o Society itself can be divided into various strata according to the
parameters of age and roles
o Not only are people and roles within every stratum continuously
changing, but so is society at large
o The interaction between individual aging people and the entire society
is not stagnant but remain dynamic.
E. PERSON ENVIRONMENT FIT THEORY
- examines the concept of interrelationships among the competencies of a
group of persons, older adults and their society or environment.
- Lawton 1982
 - Lawton identified these personal competencies as including ego strength,
motor skills, individual biologic health and cognitive and sensory perceptual
capacities.
- as a person ages, the environment becomes more threatening and he or
she may feel incompetent dealing with it.

MORAL/SPIRITUAL DEVELOPMENT
- Illness, a life crisis or even the recognition that our days on earth are
limited may cause a person to contemplate spirituality
- The nurse can assist the client in finding meaning of their life crisis
- Spirituality is part of holistic care.

CHAPTER 3: ETHICAL & LEGAL ISSUES

ELDER ABUSE- single or repeated act, or lack of appropriate action, occurring within
any relationship where there is an expectation of trust which causes harm or distress
to an older person
A. OLDER ADULT ABUSE & PROTECTIVE SERVICES
- 3 basic categories of elder abuse:
o Domestic elder abuse – form of maltreatment by someone who has
special relationship to the person
o Institutional elder abuse – occurs in residential institution such as
nursing facilities, usually by someone who is paid caregiver, nursing
staff and other staff members
o Self neglect or self abuse
− 7 Different kinds of Elder Abuse:
o Physical Abuse -use of physical force that may result in bodily injury,
physical pain or impairement
o Sexual Abuse – nonconsensual sexual contract of any kind with an
older adult
o Emotional Abuse – infliction of anguish, pain, pain or distress through
verbal or non verbal acts
o Financial and material exploitation – illegal or improper use of an
elder’s fund, property and asset
o Neglect – the refusal or failure of a person to fulfill any part of his or
her obligations or duties to an older adult
o Abandonment – the desertion of an older by an individual who has
physical custody of the elder or by a person who has assumed
responsibility for providing care to the elder
o Self neglect – behaviors of an older adult that threaten the elder’s
health or safety

- PREVENTION OF ABUSE
➢ To increase public awareness and knowledge of the issue
➢ To promote education and training of professionals and
paraprofessionals in identification, treatment and prevention
➢ To further advocacy on behalf of abused and neglected elders
➢ To study into the causes, consequences, prevalence, treatment and
prevention of elder abuse and neglect
− Common cause of abuse: Care giver stress – physical and emotional demand
of the work
− Signs and symptoms of abuse:
 o Bruises, wounds and fractures
o Sudden change of behavior
o Unexplained genital bruises and vaginal bleeding
o Living in unclean conditions
o Malnourished dehydrated
o Unexplained disappearance of fund or valuable possesions
- Common abusers are nursing aid and orderlies who have never received
stress management training
- In most health care setting nurse is a mandated reporter, the nurse
should determine the specific reporting requirements of his or her
jurisdiction, including where reports and complaints are received and in
what form they must be made.
- Nurses must be aware at all times of the responsibility to respect and to
preserve the autonomy and individual rights of older adults. The Nurses
responsibility in this regard emanates from both legal and professional
standard

B. AUTONOMY & SELF DETERMINATION

- The right to self-determination has its basis in the doctrine of informed
consent. Informed consent is the process by which competent individuals are
provided with information that enables them to make a reasonable decision
about any treatment or intervention that is to be performed on them.
Standard of disclosure includes:
o Diagnosis
o Nature and the purpose of the treatment
o The risks of the treatment
o The probability of the success of the treatment
o Available treatment alternatives
o Consequences of not receiving the treatment
− Nurses must remember that the right to decide what shall be done for and to
oneself is a fundamental right and legal tools should be used to assist, not to
detract from the basic human right. The nurses role as advocate has a high
degree of importance.
− Doctrine and standard of informed consent are intended to apply to the
decision making of the one who is competent to make such a decision.
− Competent – one who is able to understand the proposed treatment or
procedure and thereby make an informed decision.
✓ When the person is not competent, the decision may be made by
surrogate, which known as “Substituted”

C. DO NOT RESUSCITATE ORDERS

− Specific order from a Physician, entered on the Physician order sheet, which
instruct health care providers not to use or order specific methods of therapy,
which are referred to as cardiopulmonary resuscitation (CPR).
− Competent individuals may choose to forego any treatment or care even if
the choice will result in death.
− Courts often involves Physicians, often psychiatrist and other care givers in
testifying about the mental state of the person, and the courts base in the
determination of the competency on that information
− In court determination of competency the nurse may be called to testify and
will asked information relative to the client’s behavior and verbalizations that
may offer evidence as to the person’s state of mind.
 − Medical record is very important in this proceeding and nurse may use it as
back up in the testimony.
− Supporting documentation must include client’s condition, prognosis,
summary of decision making and who was involved
− Guidelines for DNR Policies in Nursing Facilities:
o The facility must have completely trained staff available 24 hours a
day to provide CPR
o Whether CPR will be performed unless there is a DNR order.
o The conditions under which facility will issue DNR orders. These
factors should be in compliance with applicable state of law; thus it is
necessary to examine the DNR provisions of jurisdiction. Consideration
include required Physician consultations regarding medical condition
and documented discussions with the client and family members.
o That competency is established, again with proper documentation or
medical consultation, as may be indicated by applicable state of law.
o The origin of consent for the order via: via the client, while
competent; by advance Medical directive; or by a substitute or
surrogate decision maker.
o Provisions for the renewal of DNR orders at appropriate intervals with
ongoing documentation of condition to note changes.
o As required by JCAHO standards, the roles of various staff members.
The policy should be approved through all appropriate channels

WITHHOLDING AND WITHDRAWING TREATMENT

- actions related to client’s right to refuse treatment or withdraw consent for it.

D. ADVANCE MEDICAL DIRECTIVES

− Are documents that permit people to set forth in writing their wishes and
preferences regarding health care.
− It is use to indicate their decisions when they are unable to speak for
themselves.
− It permits people to designate someone to convey their wishes in the event
they are rendered unable to do so.
− Legally endorsed document that provide instructions for care (living will) or
names a proxy decision maker (durable power of attorney)
− ISSUES:
o It is not operative until the client is no longer capable of decision
making
o The policy of the provider or the judgement of the treating Physician
may not be in accord of the client wishes.

RESTRAINTS
Physical Restraints and Chemical Restraints
- should be carefully weighed against the risk of complications and the insult it the
patients dignity.
- should be used only when the patient is a danger for himself and others
- chemical restraints is by giving psychoactive pharmacological agents

ASSITED SUICIDE AND EUTHANASIA

-ensure that the elderly person has complete information when asked to make a
decision regarding health care
MEDICAL DECISION MAKING FOR A POTENTIALLY INCOMPETENT PATIENT
- in incompetent; identify appropriate proxy
- if proxy is unavailable, use best medical judgement while locating proxy

INFORMED CONSENT
- patient’s bill of right clearly outlines a person’s right to information before giving
consent to treatment

ENTERAL FEEDING
- acceptable to withhold treatment such as IV fluids, antibiotics on request of the
appropriate proxy decision maker when life prolongation is no longer the appropriate
goal
LEGAL TOOLS

1. LIVING WILL OR DESIGNATION OF HEALTH AGENTS

− Intended to provide written expressions of a client’s wishes regarding the use
of medical treatments in the event of a terminal illness or condition.
− This is not effective until:
o The attending Physician has the document and the client has been
determined as incompetent
o The Physician has determined the client has terminal condition or a
condition such that any therapy provided would only prolong dying
o The Physician has written the appropriate orders in the medical
record.
− General Provisions:
o Executed by any competent person
o Contains specific language
o Requires signature of client be witnessed
2. DURABLE OR GENERAL POWER OF ATTORNEY
− It is a legal instrument by which person can designate someone else to make
health care decision at a time in the future when he or she may rendered
incompetent.

ETHICAL CODE AND END OF LIFE CARE

1. EUTHANASIA /ASSISTED SUICIDE

− Aid in dying such as deliberate administration of drug
− The nurse should rely of patient’s need and his professional judgement
− Nurses must sharpen their ethical and analytical skills to deal effectively.
2. EXPERIMENTATION AND RESEARCH
− Permit waiving the right to informed consent under the following specific
circumstances:
o There will be no adverse effects on the rights and welfare of the subject
o The research could not be effectively be carried out without the waiver
o Whenever is possible the participants are provided with pertinent
information during or after the participation
− Only full view of the research that includes legal analysis whether a waiver of
informed consent can be justified.

3. ORGAN DONATION
 − Standard of inform consent must be adhered to with respect to both donors
and recipients
− Even when an individual signed an organ donor card, the consent of survivors
is still needed.

CHAPTER 3: COMPREHENSIVE GERONTOLOGIC ASSESSMENT

− Can be challenging because of:
➢ Communication issues
➢ Hearing and vision deficits
➢ Alterations in consciousness
➢ Complicated medical histories
➢ Effects of medication
− The geriatric assessment is a multidimensional, multidisciplinary diagnostic
instrument designed to collect data on the medical, psychosocial and
functional capabilities and limitations of elderly patients
− Performing a comprehensive assessment is an ambitious undertaking. Below
is a list of the areas geriatric providers may choose to assess:
o Current symptoms and illnesses and their functional impact.
o Current medications, their indications and effects.
o Relevant past illnesses.
o Recent and impending life changes.
o Objective measure of overall personal and social functionality.
o Current and future living environment and its appropriateness to
function and prognosis.
o Family situation and availability.
o Current caregiver network including its deficiencies and potential.
o Objective measure of cognitive status.
o Objective assessment of mobility and balance.
o Rehabilitative status and prognosis if ill or disabled.
o Current emotional health and substance abuse.
o Nutritional status and needs.
o Disease risk factors, screening status, and health promotion activities.
o Services required and received.

Components of the Geriatric Assessment

− The geriatric assessment incorporates all aspects of a conventional medical
history including demographic data, chief complaint, present illness, past and
current medical problems, family and social history, and review of systems.
There are several features of the geriatric history, however, that require
special attention given the nature of this population.

A. Demographic Data
− Full name
− Age, sex
− birth date
− Marital status
✓ Challenge: Source of history and reliability of historian.
It is challenging to obtain objective historical
information especially when it is subject to the
incomplete memory of patients with impaired cognition,
or the biased interpretation of family members and
others caregivers. You should, therefore, always note
 the identity of the historian and your assessment of
their reliability and objectivity.
B. Chief Complaint and Present Illness
− Primary reason for visit, ideally in patient's own words and duration of
presenting symptoms
− Elderly patients are famous for presenting with any combination of non-
specific, apparently unrelated and seemingly trivial complaints. Sometimes
they have no complaint at all.
✓ Challenge: First, many older patients interpret their pain or
dysfunction as "normal" signs of aging.
o Fear and denial may also play a role when patients present
with no, or irrelevant, complaints.
o In geriatrics, multiple problems are the rule. Complex
pathophysiology presents in clinically complex ways, and it is
not unusual for one organ system to signal pathology in
another.
o Insurmountable communication barriers may prevent elderly
patients from receiving effective medical attention. Cultural
incompatibilities, memory loss, depression, and hearing
impairment may all contribute to the collection of an
inadequate, or even unintelligible, description of the chief
complaint and present illness.
C. Present Illness
− Chronological narrative of reasons for patient visit.
− Persistence, change, severity, character, resolution and disabling effects of
initial symptoms.
− Presence of new symptoms and/or associated symptoms history of similar
symptoms in the past aggravating and mitigating factors
D. Past Medical History
− General state of health Childhood diseases Immunizations (Tetanus-
diphtheria, pertussis, measles, mumps, rubella, hepatitis A&B, influenza,
varicella, h. flu., polio) Chronological list of adult medical diseases, injuries
and operations (not already mentioned in "Present Illness" Hospitalizations
(not already mentioned) Allergies, including clinical description of exposure
Medications, including dosage, duration and indication Diet
✓ Challenge: Patients and caregivers alike may not know or recall
important details from medical or surgical events taking place thirty,
forty or fifty years ago. In their effort to be comprehensive and
accurate
o A thorough medication history deserves explicit attention as an
absolutely crucial part of the geriatric assessment. Because
elderly patients are so frequently on multiple medications,
prescribed by different physicians, over extended periods of
time, they are at considerable risk for adverse drug interaction
and overmedication.

− Nutrition
o Elderly are more vulnerable to inadequate nutrition for a number of
reasons.
These predominantly include:
• limited dentition or ill-fitting dentures
 • diminished appetite due to loneliness, depression or
appetite-suppressing drugs
• prevalent medical conditions including constipation,
congestive heart failure, cancer and dementia
• lack of financial resources
• non-compensated disabilities resulting in limited access
to food and/or inability to prepare meals.
o At a minimum, a nutritional assessment involves the evaluation of:
• current weight in comparison to ideal body weight, with
determination of BMI to evaluate for underweight or obesity.
• recent changes in body weight.
• current medications and their potential to affect the patient's
nutritional status.
• functional status to determine if the patient can purchase
and prepare food for himself, plus mental status with regard to
their interest in food.
• food intake by food groups for a quick estimation of
adequacy of diet.
• vitamin/mineral supplementation.
o Nutritional Health Checklist.
The Nutritional Health Checklist was developed for the Nutrition
Screening Initiative for the elderly. The patient or practitioner may
complete the questionnaire. A "yes" answer for any one of the ten
questions listed below is a flag for a potential nutritional problem:
• I have an illness or condition that made me change the kind
and/or amount of food I eat.
• I eat fewer than two meals per day.
• I eat few fruits, vegetables or milk products.
• I have three or more drinks of beer, liquor, or wine almost
every day.
• I have tooth or mouth problems that make it hard for me to
eat.
• I don't always have enough money to buy the food I need.
• I eat alone most of the time.
• I take three or more different prescribed or over-the-counter
drugs per day.
• Without wanting to, I have lost or gained 10 lbs. in the last
six months.
• I am not always physically able to shop, cook, and/or feed
myself.
o The following tests may enhance the overall nutritional assessment of
elderly patients:
• Serum albumin to help determine protein and immune
status.
• Serum cholesterol and homocysteine to determine risk level
for CVD. (Total cholesterol levels above 240 mg/dl indicate
considerable risk for CVD; levels below 160 may indicate
gastrointestinal problems.)
• Blood glucose in diabetics and periodically in non-diabetic
elders since glucose intolerance increases with aging.
• Hemoglobin/hematocrit to evaluate for anemia, a prevalent
condition in the elderly.
 • Vitamin B12 (especially in vegans, with indications of
achlorhydria and gastrointestinal problems).
E. Family History
− Presence of disease with recognized familial importance in first degree
relatives - type II diabetes, tuberculosis, cancer, hypertension, allergy, heart
disease, neurological or psychiatric disease, arthritis, osteoporosis, bleeding
tendency similar presenting symptoms in family members.

F. Social history
− Birthplace and residences (if not native born, year of entry into united states)
level of education ethnicity and race marital status quality of significant
relationships and health of partner vocation, including type of industry, past
and present industrial exposures, duration of employment and retirement
avocations, including hobbies and other interests habits, including quality of
sleep, exercise, recreation, consumption of alcohol and other drugs (including
route of administration, if applicable), tobacco use (in packyears), alcohol
use, and travel abroad significant life experiences.
✓ Challenge: The social evaluation covers a vast area of information
ranging from a patient's level of education to their views on terminal
care. In fact, the terrain is so vast and complex that epidemiologists
and clinicians alike have yet to fully embrace its tremendous impact
on health. Nevertheless, an impressive and growing body of research
demonstrates a consistent association between social exposures, such
as income gradients and interpersonal isolation, with a number of
significant health outcomes, including mortality.

G. Review of Systems
System Symptoms Possible Problems
Visual Loss of near vision Common with age macular
(presbyopia) Loss of degeneration glaucoma,
central vision Loss of stroke cataracts glaucoma,
peripheral vision Glare temporal arteritis
from lights at night Eye
pain
Auditory Hearing loss Loss of high- Acoustic neuroma,
frequency range cerumen, Paget's disease,
(presbycussis) drug-induced ototoxicity
common with age
Cardiovascular Difficulty eating or congestive heart failure
sleeping, over-fatigue, (CHF)
shortness of breath,
orthopnea
Pulmonary Chronic cough, shortness chronic obstructive
of Breath pulmonary disease
Gastrointestinal Constipation Hypothyroidism,
Fecal incontinence dehydration, hypokalemia,
colorectal cancer,
inadequate fiber,
inactivity, drugs fecal
impaction, rectal
carcinoma
Genitourinary Urinary frequency, benign prostatic
hesitancy Urinary hyperplasia (BPH)
incontinence estrogen deficiency,
destrusor instability, BPH
Musculoskeletal Proximal muscle Polymylagia rheumatica
pain/weakness Joint pain osteoarthritis, rheumatoid
Back pain arthritis osteoarthritis,
osteoporotic compression
fracture, cancer
Neurologic/ Psychiatric Syncope Transient loss of Postural hypotension,
power, sensation or seizure, cardiac
speech dysrythmia, aortic
Persistent aphasia or stenosis, hypoglycemia
dysarthria Disturbance of transient ischemic attack
gait Insomnia Loss of Stroke Parkinson's disease,
memory stroke circadian rhythm
disturbance, drugs, sleep
apnea, mood disorder
Alzheimer’s disease,
multiinfarct dementia
Extremities Leg and foot swelling Leg Osteoarthritis,
pain radiculopathy, intermittent
claudication, night cramps
CHF, venous insufficiency
Weight change Refer to Nutritional
Evaluation below

H. Physical Examination
− Although a complete physical examination is an essential part of the geriatric
assessment, our intention here is to highlight those areas that are of
particular relevance to the elderly patient.
− General Appearance
o One of the most important and useful parts of the exam is your
overall impression of the patient's state of health by observation. Just
greeting the patient and inviting him or her into the exam room gives
you valuable information about level of consciousness, mobility and
gait, muscle strength, social interactive ability, hygiene, color, and
obvious discomfort.
− Vital Signs
▪ Blood pressure -Up to 30% of patients 75 years and older will
have orthostatic hypotension, meaning their systolic blood
pressure drops by 20 or more mmHg with a change in position
from supine to standing.
Up to 5% of elderly patients have artifactual hypertension.
Atherosclerotic hardening of the brachial arteries may
artifactually raise the blood pressure as much as 10 - 20
mmHg.
▪ Heart rate - Bradycardia (heart rate < 60 bpm) is common in
the elderly. Atrial fibrillation, also occurring with increased
frequency in older adults, presents as an irregular rhythm
detectable by checking the pulse. Use the radial or carotid
artery.
 ▪ Respiratory rate - Becomes clinically significant when it rises
above 20 - 24 breaths per minute. Increased rate may be the
first sign of lower respiratory tract infection.
▪ Temperature - Elderly patients not uncommonly have lower
than average core temperatures. This is important, since an
elderly patient presenting with an infection may actually be
"febrile" with an oral temperature of 98.6° F if their baseline
temperature is 96.0° F.
− Height & Weight
o Anthropometric measurements are an essential part of geriatric
evaluation because of the high prevalence of nutritional disorders
(obesity and malnutrition) in this population. An unintentional
sustained weight loss of 10% or more requires further diagnostic
evaluation
− Head
o Check for frontal bossing (Paget's disease), temporal artery
tenderness (temporal arteritis), and asymmetrical facial or extraocular
muscle weakness or paralysis (stroke).
− Eyes
o Check for impaired visual acuity (using pocket Jaeger chart and with
patient's corrective glasses on), ocular lens opacification (cataracts),
and fundoscopic abnormalities (glaucoma, macular degeneration).
− Ears
o Check for hearing loss (patients' response to whispered commands),
cerumen in auditory canals, and faulty or ill-fitting hearing aid.
− Mouth and throat
o Remove and inspect dentures. Check for mucosal dryness
(xerostomia), dental and periodontal disease, cancerous and
precancerous lesions (eg, leukoplakia).
− Neck
o Check for thyroid enlargement and nodularity (hypo- and
hyperthyroidism, and for carotid pulses and bruits (aortic stenosis and
cerebrovascular disease).
− Cardiac
o Check for S4 (left ventricular thickening) and systolic ejection and
regurgitant murmurs (valvular arteriosclerosis).
− Pulmonary
o Exaggerated dorsal kyphosis in elderly women with osteoporosis may
mimic the barrel chest of a patient with emphysema.
− Breasts
o Nearly half of breast carcinomas occur in elderly women. Replacement
of glandular tissue with fatty and fibrous tissue may make findings on
physical exam confusing. Fortunately, it also improves the sensitivity
of mammography.
− Abdomen
o Check for presence of abdominal aortic aneurysm that can be
palpated as a pulsatile mass, typically greater than 3 cm across.
− Genital/Rectal
o Check for atrophy of the vaginal mucosa; bladder, uterine or rectal
prolapse; and urinary leakage. Obtain a Pap smear if patient has not
had two negative smears within the past three years.
 o Ovaries are not palpable in elderly women, meaning any adnexal
mass is suspicious for cancer.
o Prostate nodules, rectal masses and/or occult blood may be the first
signs of prostate or colorectal cancer.
− Extremities
o Check for Heberden's nodes at distal interphalangeal joints
(osteoarthritis), diminished or absent lower extremity pulses
(peripheral vascular disease), pedal edema (venous insufficiency,
congestive heart failure), and abnormalities of the feet
(onychomycosis, bunions, pallor, and skin atrophy).
− Musculoskeletal
o Check for muscle wasting (atrophy), dorsal kyphosis and vertebral
tenderness (osteoporosis), diminished range of motion (arthritis) and
pain.

− Skin
o Check for premalignant lesions (actinic keratoses), squamous and
basal cell carcinomas and malignant melanoma; skin over pressure
points for erythema and ulceration (pressure sore) in immobilized
patients; unexplained bruises (elder abuse).
− Neurologic
o Perform mental status examination (cognitive impairment).
− Check for ataxia, postural sway (patient stands with feet together and closes
eyes), and lower extremity weakness (sitting in and rising from chair), all of
which may contribute to falls.
− Check for tremor (with rigidity and diminished facial expression, may
represent Parkinson's disease.)

I. FUNCTIONAL EXAMINATION
− direct examination of a specific capability.
− The functional assessment has become an indispensable part of the geriatric
assessment, for a number of reasons:
o As patients live longer with chronic incurable conditions, they survive
longer periods with functional impairments that require some sort of
medical and social response.
o Our society places great emphasis on autonomy and independence,
both of which are directly threatened by functional disability.
o In the geriatric patient, the first sign of a medical problem is
commonly manifest as a change in functional status.
o From a cost-of-care standpoint, effective medical management is that
which takes into account total function rather than revolving around
crisis management of recurrent, acute symptoms.
− Activities of Daily Living
o The ADLs are self-care activities that people must accomplish to
survive independently. They include bathing, dressing, toileting,
transferring, continence and feeding. The sequence is not arbitrary;
patients generally lose these skills in that order and they are regained
in the reverse order during rehabilitation
o Independent functioning is based on actual status and not ability.
Patients who refuse to perform a function are considered not able to
perform the function even though they are able.
 − Instrumental Activities of Daily Living
o IADLs are those higher-level activities people must perform in order to
remain independent in a house or apartment. They include the
functional ability to shop, prepare food, clean house, do laundry, drive
or use public transportation, administer medications, and handle
finances.
o An example of the distinction between ADL and IADLs is the ability to
simply eat a meal versus the ability to prepare it
H. Neuropsychiatric Examination
− will focus specifically on the assessment of cognition and mood and their
implications for substance abuse and competency.
− Cognitive Assessment
o involves the basic processes of perception, attention, memory,
reasoning, decision-making and problem solving.
o Before testing cognition, it is important to know that the patient s
primary sensory abilities (vision and hearing) are intact, since deficits
in primary sensation could mislead you to conclude that the patient
was cognitively impaired
o the best-validated and most widely used instrument is the Mini Mental
State Exam (MMSE) originated by Folstein, et al.
− Mood Assessment
o Undiagnosed and untreated major depression is one of the most
significant contributors to excess morbidity and mortality in geriatrics.
o Major depression is diagnosed using the core criteria of the Diagnostic
& Statistical Manual of Mental Disorders, 4th Ed (DSM-IV)/ Depression
DSM-5 Diagnostic Criteria
o The DSM-5 outlines the following criterion to make a diagnosis of
depression. The individual must be experiencing five or more
symptoms during the same 2-week period and at least one of the
symptoms should be either (1) depressed mood or (2) loss of interest
or pleasure.
▪ Depressed mood most of the day, nearly every day.
▪ Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day.
▪ Significant weight loss when not dieting or weight gain, or
decrease or increase in appetite nearly every day.
▪ A slowing down of thought and a reduction of physical
movement (observable by others, not merely subjective
feelings of restlessness or being slowed down).
▪ Fatigue or loss of energy nearly every day.
▪ Feelings of worthlessness or excessive or inappropriate guilt
nearly every day.
▪ Diminished ability to think or concentrate, or indecisiveness,
nearly every day.
▪ Recurrent thoughts of death, recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan
for committing suicide.
▪ To receive a diagnosis of depression, these symptoms must
cause the individual clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
The symptoms must also not be a result of substance abuse or
another medical condition.
 − Substance Abuse
o Due to their high prevalence of sleep disturbances, hypnotics like
benzodiazepines are frequently prescribed (often inappropriately) to
older patients, sometimes resulting in abuse. Including an alcohol
screen in the geriatric assessment is important.
o A number of factors place elderly patients at increased risk for
alcoholic complications. They include:
▪ a decrease in lean body mass
▪ diminished efficiency of hepatic metabolism
▪ an increase in brain sensitivity to alcohol
▪ a high prevalence of medical and psychosocial
comorbidities
▪ a high incidence of alcohol-drug interactions due to
polypharmacy
o In assessing a person's risk of alcoholism, questions about total
volume of consumption is less useful than questions about frequency,
pattern and consequences of drinking too much.
o CAGE Questionnaire for Alcoholism
▪ Cut down- Have you ever felt you should cut down on
your drinking?
▪ Annoyed- Have people annoyed you by criticizing your
drinking?
▪ Guilty- Have you ever felt bad or guilty about your
drinking?
▪ Eye-opener- Have you ever had a drink first thing in
the morning to steady your nerves or get rid of a
hangover?

Chapter 4: Influences on Health & Illness

1. CULTURE
− is the shared learning beliefs, expectations and behaviors of a group of
people.
− cultural knowledge is transmitted from one another through the process of
Enculturation
− Cultural Awareness:
o What are my personal beliefs about older adults from different
cultures?
o What experiences have influenced my values, biases, ideas and
attitudes toward older adults from different cultures
o What are my values as they relate to health, illness an health related
practices?
o How do my values and attitudes affect my clinical judgements?
o How do my values influence my thinking and behaving?
o What are my personal habits and typical communication patterns
when interacting with others?
o How would these be perceived by older adults of different cultures?
− Acculturation is a process that occurs when a member of one culture groups
adopts the values, beliefs, expectations and behaviors of another group.
 − Assimilation is the extreme case of acculturation, when member of one
culture becomes completely accepted by the host culture and is no longer
seen as distinct. It requires:
o The disappearance of outward behavior traits that distinguish an
individual as different from a member of the host culture
o Disappearance of exclusive and discriminatory behavior among
members of the host culture toward the new comer.
− Skills for culturally competent care
o Increased awareness
o Increase in knowledge and skills
o Handshake - greetings
o Silence – respect to the speaker
o Eye contact – honest, trustworthy, truth, equality
2. FAMILY
− Has important role in the lives older person
− “What should we do?” common question when older person start to have
problems
o Deal with relative’s perceptions and feelings
o Approach your family member in a way that prevents him or her from
feeling helpless
o Suggest only one change or service at a time.
o Suggest a trial method
o Focus on your needs – focus on family needs
o Consider who has “listening leverage”
− Decision about a care facility
o To move an older family to a facility is difficult for the most of the
family
o Decisions filled with guilt, sadness, anxiety, doubt and anger even
when older adult make decision.
▪ Sources of guilt:
• Pressures and comments from others (I would never
place my mother in care facility)
• Family tradition (may family will take care of me)
• The meaning of nursing care facility placement
(abandoning)
• Promises (till death do us part..)
− Interventions to support family caregivers:
o Understanding family caregiver’s medical condition
o Improving coping skills
o Dealing family issues
o Communicating effectively with elder person
o Using community services
o Long term planning – empower caregivers, increase confidence and
competence
o Help caregiver set realistic goals and expectations
o Provided the caregiver needed skills
o Enhance caregiver decision making
o Help caregivers solve problem
▪ Respite Program – family member are better able to
tolerate long term caregiving if they obtain respite-
“relief” or “time off”
− Working with families of older adults
 o Identify who is the client and who is the family – who is the family as
defined by the older person? -families are not only by blood
o Assess the family – willingness to care, ability to provide care
o Past relationships -poor relationships, history of abusive behavior,
emotional intensity, affection, parental or spousal disability
o Family dynamics- ways they interact to each other, family alliance,
pattern of communication
o Roles – role of each person have, assignment in caregiving
o Loyalities & obligations – how much family “owe” the older person,
indebted in providing care because how much the older person care
them in the past
o Dependence and independence
o Caregiver stress – assess the nature and extent of stress, care giver
support system.

OVERVIEW

AGING
- normal process of time related change, begins with birth and continuous throughout life
- multidimensional process of physical, psychological, and social change

YOUNG OLD- 65-74

MIDDLE OLD- 75-84
OLD OLD- 85-100
ELITE OLD- OVER 100

GERONTOLOGY
- from greek geras (old age) and iatrike (medicine), is the branch of medicine concerned with
medical problems and care of older people
- study of aging process
- nightingale was the first geriatric nurse
- 1960-1970 the greatest evolution of gerontological nursing
-developed in 1969 by ANA
-term gerontological nursing replaced the term geriatric nursing in the 1970s
- “core business of health care”

ROLES OF GERONTOLOGIC NURSE

- researcher
- nurse leader
- educators
- patient advocates
- administrators
- primary care providers focus on health promotion, disease prevention, long term
management of chronic conditions

GERONTOLOGICAL NURSING
- Defined as nursing care for elderly patients with a focus not only on illness, but on overall
health and wellness
- provide treatment for new and ongoing medical conditions and help patients and their
families learn to manage a variety of health issues