Environmental

and Safety
Factors
NURS 355 Care of Healthy Adults and Elderly
Populations
Environmental and Safety Factors

Physical hazards Falls

Lighting Transmission of pathogens
Obstacles Pollution
Bathroom hazards Disasters
Motor vehicle accidents Natural
Poison Man-made
Fires

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 Environmental Pollution

Can involve air, water, and food

Carcinogens and other chemicals can lead to diseases
such as skin, gastrointestinal and respiratory disorders
and cancer
EPA and OSHA have guidelines regarding occupational
and residential exposure
Health departments have regulations regarding food
handling
Important for the nurse to educate, screen and
advocate for protections to help prevent illness and
disease
 Hinkley, Ca. 1993

Water company near

Barstow, Ca. let rust
retardant chemicals
seep into groundwater
Resulted in clusters of
various diseases such as
rashes and different
types of cancers: a
public health concern
Class action suit
resulted in one of the
biggest plaintiff rewards
Factors Influencing Safety

Developmental stage
Adult
Elderly
Individual risk factors
Sensory and cognitive status
Impaired mobility
Lifestyle choices
Individual risk factors
Lack of safety awareness
Nursing Management

Assessment Diagnoses
Patient-centered Risk for falls

Home environment Impaired home maintenance

Factors Risk for injury

Activity/Exercise Deficient knowledge

Medication history Risk for poisoning
History of falls Risk for suffocation
Home maintenance/Safety Risk for trauma
Nursing history
Nursing Management, cont.

Planning Implementation
Goals and outcomes Health promotion
Prevent and minimize safety Individualization of
threats implementation
Measurable and realistic Developmental stage
May include active patient Lifestyle
participation
Environment
Setting priorities
Basic needs
Teamwork/collaboration
General preventive measures
Lighting
Changing the environment
Nursing Management, cont.

Evaluation Expected outcomes

Are the patients expectations Safe physical environment
met?
Patient expectations have been
Are the familys expectations met
met?
Patient is knowledgeable about
Patient outcomes safety factors and precautions
Monitor care Patient remains free of injury
Measure outcomes for each
diagnosis
Continually assess needs for
additional support
Stress

The inability to cope with perceived demands or threats to ones mental,

emotional, and spiritual well-being
What is considered stressful varies from person to person and from one
situation to another
Types of stress
Physiologic stressors
Emotional/psychologic stressors
Type, duration, and intensity of a stressor influence an individuals adaptive
response
Examples of Stressors

Physiologic Psychologic/Emotional

Burns Cancer diagnosis

Chronic pain Marital problems

Hypothermia Failing an examination

Infectious disease Inadequate financial resources

Loss of a family member
Excessive noise
Caring for a disabled child
Starvation
Winning or losing an athletic
Running a marathon event
Birth of a baby Winning the lottery
Factors Affecting Response to
Stressors
Internal and external influences
Key personal characteristics
Resilience
Hardiness
Attitude
Optimism

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Interrelation of Body Systems
Effects of Stress on Health

Acute stress causes physiologic Effects of Stress

changes Cognitive function
Important to adaptive survival Poor concentration
Excessive or prolonged Impaired decision making

Physiologic responses can be Memory problems

maladaptive
Behavior
Lead to harm and disease
Withdrawing from others
Decreased immunity
Irritability
Substance abuse
Effects of Stress on Health, cont.

Stress-induced
immunosuppression may
exacerbate or increase risk of
progression of immune-based
diseases
Multiple sclerosis
Asthma
Rheumatoid arthritis
Cancer

Bannastock/Thinkstock
Effects of Stress on Health, cont.
Obesity and depression are often
exacerbated by stress
Chronic stress can change DNA
and accelerate cellular aging
Leads to chronic illness
Contributes to escalating health
care costs
Early life stressors are even
more destructive
Coping
Cognitive and behavioral efforts
to manage specific external or
internal stressors that seem to
exceed available resources
Goodshoot/Thinkstock
Coping resources are
characteristics or actions used to
manage stress
Include factors within the person
or environment
Nurses can help support,
develop, and expand these
resources
Coping, cont.

Emotion-focused coping Problem-focused coping

Manage emotions resulting from Find solutions to resolve
a stressful event problems causing stress
Helps to decrease negative Examine challenge objectively
emotions
Take action to address the
Creates a feeling of problem and reduce stress
well-being

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A patient who is newly diagnosed with cancer is scheduled to
consult with an oncologist in several days. What would be the
best coping strategy for the nurse to recommend at this time?

A. Go away for a few days to forget about the situation.

B. Talk to family and friends about negative feelings

C. Seek information about the cancer and treatment

options.

D. Wait to see what the oncologist recommends for

treatment.
A patient who is newly diagnosed with cancer is scheduled to
consult with an oncologist in several days. What would be the
best coping strategy for the nurse to recommend at this time?

A. Go away for a few days to forget about the situation.

B. Talk to family and friends about negative feelings.
C. Seek information about the cancer and treatment
options.
D. Wait to see what the oncologist recommends for
treatment.

Rationale: For problems that can be changed or controlled,

the
best coping strategy is problem-focused coping
(not
emotion-focused coping). Seeking information
related to treatment options is problem-focused,
will
Relaxation Strategies

Relaxation
A state of physiologic and
psychologic deep rest
Characterized by decreased
sympathetic nervous system
activity

Comstock/Thinkstock
Relaxation Strategies, cont.

Breathing Meditation
How one breathes affects every Three basic types
aspect of life
1. Concentration: Directs the mind to
Simplest, most effective way to a single focus (breath or a mantra)
stop stress is to breathe deeply 2. Guided: Similar to guided imagery
and slowly
3. Mindfulness: Focus on all
Relaxation (abdominal) breathing sensations, perceptions, cognitions,
and emotions as they arise moment
to moment in the field of
awareness

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1.jpeg
Relaxation Strategies, cont.
Imagery
Calming effect
Focuses mind
Uses all senses
Causes physiologic and
emotional changes
Guided imagery: Images
suggested by another person
Useful for targeting specific
diseases, problems, or stressors
Music
Reduces stress
Balances mind and body
Decreases anxiety/pain while
enhancing relaxation
Soothing tempo: 60 80
beats/min
No lyrics/Low-pitched tones
best for relaxation
Fast-tempo: stimulating and
uplifting
Relaxation Strategies, cont.

Muscle relaxation Massage

Muscle tension: a universal Systematic manipulation of soft
reaction to stress tissue
Muscle relaxation elicits the Reduces tension
relaxation response Enhances health and healing
Two types of muscle relaxation: Adds touch: An essential human
Progressive need
Passive

Photodisc/Thinkstock
Nursing Management: Assessment

Signs and symptoms of stress response

Physical
Increased HR and BP, hyperventilation, or headache

Behavioral
Anxiety, irritability, or impaired speech

Cognitive
Self-reports of forgetfulness or indecision

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Nursing Management:
Implementation
First step in managing stress is
being aware it is present
Includes identifying and
expressing stressful feelings
Nurses facilitate and enhance
processes of coping and
adaptation
Informing patients about the
benefits, as well as negative
effects of CATs, such as St.
Johns wort or kava, is important
Effective stress management
provides a sense of control over
the situation
Recognize when patient needs to
be referred to a professional for
counseling
Substance Abuse

Overindulgence of a substance that has a negative impact on psychologic,

physiologic, and/or social functioning of an individual
Substance is defined as a drug, chemical, or biologic entity that is self-
administered
Almost every drug of abuse harms some tissue or organ in addition to the
brain
Damage results from both the substance and behavior related to its use
Prevalent Health Problem

Substance abuse and substance dependence are psychiatric diagnoses

Early recognition and identification is crucial to successful treatment
outcomes

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Commonly Abused Drugs

Nicotine
Most commonly abused drug
Highly and rapidly addictive stimulant
Leading cause of preventable illness and death in U.S.
Alcohol
Alcoholism: a progressive, potentially fatal disease
Affects almost all cells of the body
Complex effects on CNS neurons

Stimulants
Cocaine
Amphetamines
Caffeine
Commonly Abused Drugs, cont.

Depressants Cannabis
Sedative-hypnotics Most widely used illicit drug in
North America
Barbiturates
Thorough history and physical
Benzodiazepines
exam to identify patterns of use
Barbiturate-like drugs
THC: key active ingredient
Opioids Treatment of withdrawal is
Heroin supportive

OxyContin/Vicodin
Nursing and Collaborative Care
Tobacco Use
Effects of nicotine use and complications
Smoking is most harmful method of use
Impacts brain similar to cocaine and other stimulants
Can injure nearly every organ

Hazardous in any form

Dangerous for non-smokers
Nurses play an important role in motivating and teaching users to quit
using tobacco
Nursing and Collaborative Care
Tobacco Use, cont.
Nursing and Collaborative Care
Tobacco Use, cont.
Five As for Individuals
Who Desire to Quit
Ask: Identify all tobacco
users at every contact
Advise: Strongly urge all
tobacco users to quit
Assess: Determine
willingness to attempt
quitting
Assist: Aid patient in
developing a plan to quit
Arrange: Schedule follow-up
Five Rs for Individuals
Unwilling to Quit
Relevance: Ask patient to
indicate why quitting is
personally relevant
Risks: Ask patient to identify
negative consequences of use
Rewards: Ask patient to
identify potential benefits of
quitting
Roadblocks: Ask patient to
identify barriers to quitting
Repetition: Repeat process
with every visit
Nursing and Collaborative Care
Tobacco Use, cont.
Variety of products available to help with cravings and withdrawal
symptoms
Tobacco cessation program participation is recommended in conjunction
with nicotine replacement therapy
Women are less successful than men in quitting smoking
It is always important to quit

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Effects of Alcohol Use

Increased dopamine levels in the brain

CNS depression
Absorbed directly from stomach and small intestine
Alcohol abuse
Numerous, serious health problems
Wernickes encephalopathy
Korsakoffs psychosis
Risk factor for several types of cancer
May also interfere with compliance with therapeutic regimens

Potentiation and cross-tolerance associated with drug interactions

Nursing and Collaborative Care
Alcohol Dependency
Alcohol Withdrawal Syndrome Alcohol Withdrawal Delirium
Occurs with abrupt cessation Serious complication
Onset varies with drinking Onset from 30 120 hours after
patterns last drink
Symptoms within 4 6 hours Can be fatal
after last drink
Prevented or controlled with
May last up to 14 days administration of
Does not always progress in a benzodiazepine
predictable manner
Nursing and Collaborative Care
Stimulant Abuse
Overdose
Occurs frequently
No antidotes
Death possible
Withdrawal
Rarely causes hospitalization
Craving is intense

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Nursing and Collaborative Care
Depressant Abuse
Unintentional overdose occurs Overdose
frequently with recreational use Sedative-hypnotics
Unpredictable potency and Opioids
purity
Withdrawal
Sedative-hypnotics
Opioids
Nursing Management of Substance
Abuse
Diagnoses Implementation
Physical/Psychosocial issues Health promotion
Planning Acute intervention
Physiologic functioning Ambulatory and Home Care
Acknowledge a problem exists Motivational interviewing
Explain psychologic and
physiologic effects of substance
abuse
Abstain from use
Cooperate with treatment
A patient tells the nurse that she is worried about her 22 year old son
who has been socializing with some friends she thinks are using drugs.
The best response by the nurse to the patients concern is:

A. You need to stop his association with these friends to

prevent him from using drugs.
B. Most young people experiment with drugs, but very few
become addicted to illegal substances.
C. You should learn about the early signs and symptoms of drug
abuse and share your concerns with your son.
D. You need to make an appointment for your son with a drug
counselor so he can be taught about the harmful effects of
drugs.
A patient tells the nurse that she is worried about her 22 year old son
who has been socializing with some friends she thinks are using drugs.
The best response by the nurse to the patients concern is:

A. You need to stop his association with these friends to

prevent him from using drugs.
B. Most young people experiment with drugs, but very few
become addicted to illegal substances.
C. You should learn about the early signs and symptoms of drug
abuse and share your concerns with your son.
D. You need to make an appointment for your son with a drug
counselor so he can be taught about the harmful effects of
drugs.

Rationale: Early recognition and identification of a person with

substance dependence is crucial to successful treatment
outcomes. Option c encourages open communication
between parent and child.
Gerontologic Considerations

Older adults do not fit the image of abusers

Mimics medical conditions
Problems go unrecognized and untreated
Commonly abuse prescription drugs
Never too late for treatment

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Demographics of Aging

Aging population Increasing life expectancy

Surviving acute illness
anticipated to continue

Living with chronic illness Men: 77.8

Becoming more educated and Women: 80.8

resourceful Young old: 65 74
More ethnically diverse Old old: 85 and older
Frail old have some dysfunction

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Attitudes Toward Aging

Aging is normal
Older adults have diverse characteristics
Care should not be based on age alone
Myths and stereotypes can lead to poor care
Ageism leads to discrimination and disparate care

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pg
Age-Related Changes

Biologic Aging Physiologic Changes

Normal part of aging

Affect every body system
Individual to each person
The nurse teaches a student nurse about health care disparities
and older adult women. Which statement, if made by the
student nurse, would indicate an understanding of the
teaching?

A. Women have a shorter life expectancy than men.

B. Women have fewer financial resources than men.
C. Women are not likely to be a caregiver to their
spouses.
D. Women more often have age-related cognitive
impairments.
The nurse teaches a student nurse about health care disparities
and older adult women. Which statement, if made by the
student nurse, would indicate an understanding of the
teaching?

A. Women have a shorter life expectancy than men.

B. Women have fewer financial resources than men.
C. Women are not likely to be a caregiver to their
spouses.
D. Women more often have age-related cognitive
impairments.

Rationale: Factors that are directly related to older women

and
health care disparities include limited financial
resources and greater longevity.
Vulnerable Factors for the Elderly

Chronically Ill Older Adults Homeless Older Adults

Incidence of chronic illness Numbers are increasing.
triples after age 45
Mortality rates are 3 times
Older Adult Women higher than for those with
housing.
Longevity increases vulnerability
Have more health problems and
An aging body
appear older
Being female
Require an interdisciplinary
services approach
Vulnerable Factors for the Elderly,
cont.
People older than 65
Less likely to live in cities
Barriers to health care access
Frequently have decreased
ability to perform self-care:
leads to noncompliance
Less likely to engage in health
promotion
Increased risk if member of a
minority group
Vulnerable Factors for the Elderly,
cont.
Cognitively impaired older adults Frail older adults
Evaluate memory loss Usually older than 75
Use aids to improve function Physical, cognitive, or mental
dysfunction
Control the environment
Memory improvement Risk factors
techniques Disability
Assistive devices Chronic illnesses
Dementia
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Culturally Competent Care for the
Older Adult
Loss of ethnic ties
Loss of ethnic support
Security/Safety concerns
Assess health perceptions
An older adult male is having his blood pressure checked by the
nurse at the senior center. The nurse notes large bruises on
both of his upper arms. When questioned by the nurse about
the cause of the bruises, the patient responds, I must have
bumped myself. Which is the most appropriate initial action
for the nurse to take?

A. Ask the patient if anyone has been mistreating him.

B. Report the finding to the state agency for elder abuse.
C. Question the patient about his living situation and
activities.
D. Reassure the patient that information will be
confidential.
An older adult male is having his blood pressure checked by the
nurse at the senior center. The nurse notes large bruises on
both of his upper arms. When questioned by the nurse about
the cause of the bruises, the patient responds, I must have
bumped myself. Which is the most appropriate initial action
for the nurse to take?

A. Ask the patient if anyone has been mistreating him.

B. Report the finding to the state agency for elder abuse.
C. Question the patient about his living situation and
activities.
D. Reassure the patient that information will be
confidential.

Rationale: The best approach in this situation is for the

nurse to
complete a thorough history and physical that
includes screening for mistreatment.
Social Support and the Older
Adult
Family caregivers
Primary and preferred
Semiformal levels of support
Clubs, religious organizations,
neighborhoods, senior centers
Formal systems of support
Social welfare agencies, health
facilities, government agencies
Elder Mistreatment/Abuse
2 10% of community-dwelling
older adults in the U.S. are
abused, neglected, or exploited
by trusted others
Mortality risk is 3 times higher
Self-Neglect
Social Services for Older Adults

Area Agency on Aging Medicare

Federally-funded programs Federally funded insurance for
people > 65
Delivered at the state and local
level Also covers those < 65 with
disabilities or end-stage kidney
disease
Medicaid
State-administered, needs-based
program
Assists eligible low-income
people with medical expenses

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Care Alternatives for Older Adults

Community services
Housing for older adults
Adult day care
Care Alternatives for Older Adults,
cont.
Special care needs
Need assistance with ADLs
Cognitively impaired
Homebound
No longer able to live at home
Homeless
Home Health Care
Homebound
Intermittent or acute health
needs
Supportive caregiver
involvement
Long-Term Care
Transition may be difficult for
patients and families
Relocation stress syndrome
Legal and Ethical Issues

Many complex and emotional situations may arise for older adults
Decisions may be difficult
Nurses can help
Stay informed about concerns
Be knowledgeable about resources
Advocate for patients and resolution

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pg
Gerontological Nursing

Complex, skilled, creative care

Older adult disease symptoms are often atypical and underreported
Patients may be fearful and anxious about health problems and
institutions of care

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Nursing Management

Assessment
Attends to primary needs first
Focuses on functional abilities
Comprehensive
Involves an interdisciplinary
team and approach
Nursing Management, cont.

Diagnoses Implementation
Defined by age-related changes Health promotion
Planning
Identify strengths and abilities
Gain a sense of control
Feel safe
Reduce stress
Polypharmacy and the Elderly

Elderly make up 13% of

the population but they
consume approx. 30% of
the prescriptions!
Nearly 40% of elderly
admitted to hospitals
have 7 or more
prescriptions
Polypharmacy:
definitions vary: taking
5 or more prescriptions
 Polypharmacy

Elderly frequently have

to manage multiple
medications

May be non-compliant
for many reasons such as
Misunderstanding
Forgetfulness
Financial barriers
Effects of Aging on Drug
Metabolism
 Consider Beers Criteria

Evaluate the medication Psychiatric medications

regimen for eldery
Barbituates
clients relative to the
following medications: Benzodiazapines
Anticholinergics Hormones
Antispasmotics Hypoglycemics
Antithromotics Analgesics
Cardiovascular meds Antiinflammatory meds
(ex: ASA, NSAIDS)
Antiarrhythmics
Muscle relaxants
Antihypertensives
 IMPORTANCE

Elderly have more chronic diseases: need more and

different medications

Polypharmacy in the elderly can lead to

Adverse reactions and interactions
Orthostatic hypotension>FALLS!
Development of or worsening of delirium and dementia
Anticholinergic side effects
Nursing Management, cont.

Evaluation
Improvement in ADLs, IADLs, mental status, disease symptoms
Patient reports improvement in health
Patient confirms treatment is effective
Patient verbalizes that treatment is worthwhile
Document interventions used and degree of improvement
Determine whether mandates for reimbursement are met
Never look down on anybody unless
you're helping them up.
The Reverend Jesse Jackson
References

Beers, M. (1997). Explicit criteria for determining potentially inappropriate

medication use by the elderly: An update. Archives of Internal Medicine,
157(14), 15311537.
Icahn School of Medicine at Mount Sinai (n.d.). Brain reward pathways.
Retrieved January 5, 2014, from
http://neuroscience.mssm.edu/nestler/brainRewardpathways.html
Inner Health Studio (2014). Passive progressive relaxation. Retrieved January 5,
2014, from http://www.innerhealthstudio.com/passive-progressive-
relaxation.html
Lewis, S. L., Dirksen, S., Heitkemper, M., & Bucher, L. (Eds.). (2014). Medical-
surgical nursing: Assessment and management of clinical problems (9th ed.).
St. Louis, MO: Elsevier Mosby.
Mind Tools (2014). Physical techniques: Deep breathing, progressive muscle
relaxation & the relaxation response. Retrieved January 5, 2014, from
http://www.mindtools.com/stress/
RelaxationTechniques/PhysicalTechniques.htm
References, cont.

Potter, P. A., Perry, A., Stockert, P. A., & Hall, A. M. (Eds.). (2013).
Fundamentals of nursing (8th ed.). St. Louis, MO: Elsevier Mosby.