Seminar on

Geriatric Consideration in Nursing

Submitted To:-Mrs.Dr. Ratna

Philip M.Sc (N), Ph.D.,

Principal,

MAMATHA COLLEGE OF NURSING

KHAMMAM

Submitted By:-Mrs. Udaya

Sree.G

M.Sc., Nursing Ist Year

MAMATHA COLLEGE OF NURSING

KHAMMAM

GERIATRIC CONSIDERATIONS IN NURSING

I. Introduction

Geriatrics is a sub-specialty of internal medicine and family medicine that focuses on health care of elderly people. It aims to promote health by preventing and treating diseases and disabilities in older adults. There is no set age at which patients may be under the care of a geriatrician, or physician who specializes in the care of elderly people. Rather, this decision is determined by the individual patient's needs, and the availability of a specialist.

Geriatrics, the care of aged people, differs from gerontology, which is the study of the aging process itself. The term geriatrics comes from the Greek meaning "old man" and meaning "healer". However, geriatrics is sometimes called medical gerontology.

Life expectancy is rising at rates which call for the proper preparation of nurses to take good care of the rapidly increasing number of the aged.

II. Definition

Geriatric nursing is the specialty that concerns itself with the provision of nursing services to geriatric or aged individuals.It outlines the state of art guidelines for geriatric care that are useful to a nurse practitioner and clinical nurse specialist who encounters aging person in practice. Due to their complexity, aged people always deserve personal attention. Nurses address physical, psycho social, cultural and family concerns as well as promoting health and emphasizing successful aging.

-The ANA Congress on Nursing practice

III. Geriatric Nursing: A Growing Specialty

The greatest area of potential job growth and evidence based practice for the future may well be geriatrics.  According to the World Health Association, the world's population aged 60 and over will more than triple from 600 million to 2 billion in the next forty years.  The fastest growing group is those over the age of 80.  This increase in population is global.  No longer will a concern of the more developed nations, the number of elders rise in developing countries from 400 million in 2000 to 1.7 billion by 2050.  The challenge that all nations face is how to promote healthy, active aging and quality of life, without over-medicalizing and over-burdening our health care systems. There is a growing demand for a skilled geriatric nursing workforce to provide quality care across a wide range of health care settings.  The exponential growth in the health care costs for older adults creates a call greater accountability.  There is mounting pressures for health care providers and settings to demonstrate cost effectiveness and safe, quality outcomes.  Building nursing expertise in geriatric practice has been embraced by national nursing organizations around the globe. From expanding geriatric education in schools of nursing, to mandating evidence based geriatric practice in accreditation standards for health care settings, the push is on! 

IV. Role of a Geriatric Nurse

The Nurse’s Role in Caring for Older Adults

• Generalists– Direct care providers– Case managers– Nurse leaders– Educators– Patient advocates– Administrators

• Advanced practice geriatric nurses – Primary care providers focus on

Health promotion Disease prevention Long-term management of chronic conditions

V. Typical Job Responsibilities of a Geriatric Nurse

Geriatric nursing requires a lot of work with physicians, and a good deal of your job will be in a support role to the physicians that serve your patients. One of the ways you will provide support to physicians is through assistance with examinations. Additionally, you will frequently be required to carry out treatments, including administering prescribed drugs and other remedies. You will also be responsible for preparing patients for treatments and setting up equipment. You will be expected to maintain an organized, updated chart for patients in your care so that physicians will have an accurate record on which to base their recommendations for care.

The remaining duties of a geriatric nurse fall under mental health and more general care. You may find yourself required to change sheets, feed patients, and bathe them. Additionally, your job may include interpersonal communication with the patient as well as the patient’s family for moral support and decision making.

VI. Most Common Geriatric problems

Some of the most common geriatric problems include declining mental and physical health. Specifically, issues like arthritis, heart disease, anxiety and depression tend to affect elderly people to a greater degree than they do other people. Several geriatric problems can be corrected or cured by medical and mental health professionals while progressive disorders, such as Alzheimer’s disease, cannot be cured.

Nurses specializing in geriatric medicine regularly treat a variety of health issues that affect older adults. Some doctors also help patients avoid certain geriatric health problems, such as stroke and organ failure, by helping patients make lifestyle changes, which include exercise, a healthy diet and eliminating bad habits like smoking and alcohol abuse. Without attention and treatment, common geriatric problems like diabetes, high cholesterol and hypertension can become life-threatening for geriatric patients.

Other geriatric problems, such as hormonal changes, sleep disorders, skin changes and nutritional deficiencies, may require medical intervention and many are addressed by changes in diet and exercise. More serious problems, such as prostate cancer, liver failure, kidney failure and heart disease, may even require surgical treatment. Mild geriatric problems

such as dry mouth, vision problems and sexual dysfunctions are often treatable with medication and are not considered to be life-threatening.

VII. Common characteristics for geriatric patients

There are many common characteristics many geriatric patients share. As people age, they often lose some physical and mental function and are at an increased risk for injury and certain illnesses. While many conditions and medical concerns can affect patients of any age, geriatric patients often require different care and testing due to their age.Heart disease and other cardiovascular problems are a major concern for elderly patients. Advanced age weakens the heart, and arteries become harder due to plaque build-up and loss of flexibility. These issues make it harder for the heart to pump blood throughout the body, which can lead to high blood pressure, heart attack, and other serious problems. Geriatric patients should strive to eat a healthy diet, get regular exercise, and have their blood pressure and heart checked regularly so their doctors can promptly diagnose and treat any heart-related problems.

Older patients often suffer from bone, joint and muscle-related health concerns, such as arthritis and osteoporosis that limit their abilities to move and make them more susceptible to injury. Many medications prescribed to elderly people increase the risk of falling, so these patients should be monitored closely and follow safety precautions to prevent dangerous falls that could result in bone fractures. Calcium and vitamin D helps promote bone strength, and exercise and stretching help improve flexibility and muscle strength.

Vision and hearing tend to decline with age, so geriatric patients usually require more frequent eye and ear examinations than younger patients do. Wearing glasses or contacts or using hearing aids can help seniors compensate for partial loss of these senses. The elderly often require more frequent dental visits as well due to brittle teeth or gum problems caused by less saliva.

Urinary incontinence is a common concern for geriatric patients. While some bladder control problems are the result of aging, seniors who experience these problems should discuss them with their doctors to rule out underlying age-related serious conditions, such as prostate problems in men. Lifestyle changes and medications can help many geriatric patients gain control of their bladders.

Neurons in the brain responsible for memory start to decline as people age, so many geriatric patients experience problems with memory that may get progressively worse or develop into more serious conditions, such as dementia and Alzheimer's. Depression is another major concern among geriatric patients. Many older people develop depression as a result of losing loved ones, health problems, lack of fulfilment they once received from jobs or raising children, or just generally growing older.

VIII. Geriatric assessments

Geriatric assessments, which are tests performed on elderly patients, often include evaluations for depression or psychological disturbances. Geriatric mental health testing may be performed at clinics or by a private physician. Elderly patients with dementia often undergo short-term memory tests. A physician may also perform geriatric assessments on a patient as part of routine medical care. Examples of routine geriatric assessments include hearing and eye examinations, as well as testing for heart-related problems.

Performing a comprehensive assessment is an ambitious undertaking. Below is a list of the areas geriatric providers may choose to assess:

• Current symptoms and illnesses and their functional impact.

• Current medications, their indications and effects.

• Relevant past illnesses.

• Recent and impending life changes.

• Objective measure of overall personal and social functionality.

• Current and future living environment and its appropriateness to function and prognosis.

• Family situation and availability.

• Current caregiver network including its deficiencies and potential.

• Objective measure of cognitive status.

• Objective assessment of mobility and balance.

• Rehabilitative status and prognosis if ill or disabled.

• Current emotional health and substance abuse.

• Nutritional status and needs.

• Disease risk factors, screening status, and health promotion activities.

• Services required and received.

IX. Major Considerations in Geriatric Nursing

Elderly people generally want to live independently as long as possible, which requires them to be able to engage in self-care and other activities of daily living. Following are the some of the great concern to Geriatricians and their patients.

i) Practical concerns

ii) Functional abilities

iii) Independence

iv) Quality of life issues

To evaluate the medication regimens of older patients who might be at risk in practical considerations, clinicians should combine an evidence-based approach with knowledge of the potential effects of drug therapy. The evaluation should also be performed in the context of:

• The patient’s history of health problems• An appropriate laboratory assessment.• A gait and balance assessment.• A comprehensive physical evaluation, including:

A vision examination. A measurement of postural blood pressure. A targeted neurologic, musculoskeletal, and Cardiovascular examination

A geriatrician may be able to provide information about elder care options, and refers people to home care services, skilled nursing facilities, assisted living facilities, and hospice as appropriate.

Geriatric health care often involves treating patients with cardiovascular disease. The risk of coronary heart disease increases with age. Factors such as poor diet and obesity in elderly patients may contribute to heart-related issues.

Impaired vision is another other main concern in geriatric health. Vision problems or even blindness may result as a complication from diabetes. The elderly are more likely to develop these complications if diabetes is not properly managed.

The effects of aging can also contribute to hearing loss. This is why it is more common for the elderly to rely on the use of hearing aids. Other treatment options, such as cochlear implants may help elderly patients with hearing loss.

Addressing mental health issues may be a fundamental part of geriatric care. Many elderly individuals suffer from depression, primarily due to lack of social interaction. Feelings of isolation may occur when an elderly person is housebound. In extreme cases of depression, suicide among the elderly is a concern.

Other mental health concerns in geriatric medicine are memory loss and dementia. Cognitive reasoning may be compromised as a result of dementia due to aging. Advanced dementia may cause symptoms such as delusions and hysteria. Alzheimer's disease may be mild to advanced, and generally requires treatment such as medication and cognitive therapy.

Nutrition is a chief concern for many elderly individuals. In many cases, an elderly person who lives alone or is housebound may not receive adequate nutrition. Lack of proper nutrition may also be due to the inability to cook for him. Providing home care for an elderly individual who cannot look after himself may be a solution.

X. Nursing Diagnosis and Care

i) Cardiovascular System and Nursing diagnosis Left ventricle hypertrophy Decreased force of contraction, contractile efficiency, stroke

volume Decreased baroreceptor sensitivity and beta adrenergic response Arterial stiffening and all thickening, decreased compliance

Decreased O2 uptake by tissues

Assessment Assess BP (lying, sitting, standing) & pulse pressure Cardiac assessment: rate/rhythm/heart sounds

-note altered landmarks, distant heart sounds, extra heart sounds (S3 in CHF)

Palpate cartoid artery, peripheral pulses for symmetry Monitor heart rate and rhythm, note irregularity, ECG Assess for dyspnea with exertion, exercise intolerance

Nursing Care plan Referral for irregularities in heart rhythm, decreased or asymmetry

of pulsesSafety precautions for orthostatic hypotension- Rise slowly from lying or sitting position-Wait 1-2 minutes after position change to stand or transfer-Monitor for overt signs of hypotension: change in sensorium/mental status, dizziness, orthostasis -Institute Fall prevention strategies

Implications Decreased cardiac reserve & output Slow recovery from tachycardia Fatigue, SOB Increased premature or ectopic beats Risk of valvular dysfunction & systolic murmurs, conduction

abnormalities Risk of postural & diuretic-induced hypotension Strong arterial pulses, diminished peripheral pulses;cool

extremities Risk of inflamed varicosities

ii) Respiratory System and Nursing diagnosis Decreased response to hypoxia & hypercarbia/li> Diminished ciliary & macrophage activity Increased airway reactivity Decreased muscle strength & endurance Drier mucus membranes Decreased alveolar function, vascularization, elastic recoil Thorax & vertebrae rigid

Assessment Respirations - rate, pattern, breath sounds throughout lung fields Note thorax appearance, chest expansion Assess cough, deep breathing, exercise capacity Monitor arterial blood gases, pulse oximetry Monitor secretions, sedation, positioning which can reduce

ventilation/oxygenation

Nursing Care plan Maintain patent airway through repositioning, suctioning,

bronchodilators Prevention of respiratory infections with pulmonary Incentive spriometry as indicated, particularly if unable to

ambulate or decline in function Education on cough enhancement, avoidance of environmental

contaminants, smoking cessation Maintain hydration and mobility Provide oxygen as needed

Implications Decreased cough, deep-clearance Risk of infection & bronchospasm (airway obstruction) Altered pulmonary function - lower maximal expiratory flow

(FEV, FEV1/FVC1

- increased residual volume- reduced vital capacity- unchanged total lung capacity

Dyspnea after exertion, decreased exercise tolerance PO2, SpO2 decreased. Decreased capacity to maintain acid-base

balance Respiratory rate12-24 Decreased respiratory excursion & chest/lung expansion with less

effective exhalation

iii) Genitourinary System and Nursing diagnosis (For kidney)

Decreased functional reserve when water/salt overload/deficit Decreased blood flow, oxygenation, glomerular filtration rate

(often < 50%, measured by creatinine clearance) Tubule degeneration

- Reduced response to vasopressin- Impaired capacity to dilute, concentrate, acidify urine; impaired sodium regulation

Reduced bladder elasticity, muscle tone, capacity Weakend urinary sphincter Decreased or delayed perception of voiding signal Increased nocturnal urine production In males, benign prostatic hypertrophy

Assessment Assess renal function, particularly in acute/chronic illness Monitor blood pressure (orthostatic) Assess for dehydration, volume overload, electrolyte imbalances,

proteinuria- See addendum at end of table Determine source of fluid/electrolyte imbalance, monitor

laboratory data Assess choice/dose/need for nephrotoxic agents (e.g.,

aminoglycoside antibiotics, radiocontrast dye) and renally excreted medications. Palpable bladder after voiding due to retention

Assess for urinary incontinence, UTI Assess for abnormal urine stream, urinary retention with BPH Assess fall risk in nocturnal or urgent voiding

Nursing Care plan Maintain hydration, baseline fluid/electrolyte balance. Prepare for

fluid/electrolyte correction as indicated Monitor drug levels of renally cleared medications Calculate creatinine clearance - see addendum Monitor for normal renal function: constant serum creatinine level

to baseline Safety precautions in nocturnal or urgent voiding & postural

hypotension, institute fall prevention strategies Referral to incontinence specialists with follow-up for incontinence

management Referral to renal or urology as indicated

Caution providers regarding medications that increase urinary retention in BPH, renal toxic drugs 

See addendum at end of table for signs and symptoms of dehydration, UTI, electrolyte imbalances

Implications Risk of renal complications in illness; susceptibility to acute

ischemic renal failure & embolism Risk of dehydration, volume overload, hyperkalemia (with

potassium-sparing diuretics), hyponatremia (with thiazide diuretics), hypernatremia (with NSAIDs). See addendum

Reduced excretion of acid load Risk of postural hypotension Decreased drug clearance Risk of nephrotoxic injury by drugs In bladder, increased post-void residual urine Risk of urinary tract infection (UTI), incontinence (not a normal

finding) Nocturnal polyuria- risk for falls In males, risk of urinary hesitancy dribbling, frequency,

incontinence (BPH)

iv) Gastrointestinal System and Nursing diagnosis Decreased thirst perception Decreased esophageal motility & lower esophageal sphincter

pressure Decreased stomach motility; mucosal atrophy Decreased small intestine motility, villi, digestive enzyme secretion Decreased large intestine blood flow, motility, defecation sensation Decreased liver size, blood flow, enzymatic metabolism of

drugs; increased biliary lipids

Assessment Assess abdomen (note smaller liver), bowel sounds Monitor weight, dietary intake, elimination patterns, fluid intake Assess dentition, chewing & swallowing abilities, eating

habits/nutrition Assess lungs for basilar crackles, infection from aspiration Evaluate poor food intake

Nursing Care plan 3 day calorie count, consultation with dietician for poor

intake/unplanned weight loss. Monitor drug levels and liver function tests if on medications metabolized in liver; electrolytes, BUN/creatinine, albumin

(nutritional indicator and if low effects drug levels like digoxin) Monitor for signs of dysphagia, coughing or choking with

solids/liquids. Speech &/or swallowing evaluation as indicated Monitor for signs of aspiration particularly if decline in

function/weakness; GERD Monitor nutrition/diet intake, fluid intake, elimination particularly

if immobile. Maintain mobility. Provide laxatives if on constipating medications, e.g., narcotics

Implications Risk of dehydration, electrolyte imbalances, poor nutritional intake Risk of dysphagia, hiatal hernia, aspiration Delayed emptying of stomach with risk of maldigestion Gastroesophageal Reflux Disease (GERD) Constipation, flatulence common Risk of fecal impaction Risk of adverse drug reactions due to slowed liver metabolism

Decreased absorption of fat, carbohydrate, protein, vitamin B12, iron, folate, calcium, and vitamin D with risk of anemia, osteoporosis, malnutrition

In mouth, risk of gingivitis, tooth loss with chewing impairment

v) Musculoskelatal System and Nursing diagnosis Narrowed intervertebral disks Decreased bone mass Lean body mass replaced by fat with redistribution of fat Decrease in muscle mass & regeneration of muscle fibers Increased latency/contraction time of muscle Increased hip/knee flexion Tendon & ligament stiffening In joints, articular cartilage erosion; increased bone overgrowth &

calcium deposits

Assessment Assess functionality, mobility, symmetry and strength, fine & gross

motor skills, ADLs. Ensure joint stabilization and slow movements in ROM exam to

prevent injury "Get-up-and-Go" test 

Nursing Care plan Maintain maximal function, encourage/provide active or passive

ROM Assess for pain and provide pain medication to enhance

functionality Demonstrate/encourage muscle strengthening exercises Referrals to physical/occupational therapy Fall risk interventions, avoid restraints.

Implications Giat & balance instability common Risk of osteoporosis & fractures, osteoarthritis Decreased total body water & intercellular/interstitial fluid Decreased muscle strength & agility; slowed reflexes and reaction

time-fall risk Decreased endurance

Joint stiffness with decreased mobility Risk of injury, pain on ROM, joint subluxation, crepitus

vi) Nervous System & Cognition and Nursing diagnosis In CNS, decrease in neurons, brain size, neurotransmitters Slowed nerve impulse conduction. Decreased peripheral nerve

function

Assessment Assess baseline; periodic reassess of functional status during acute

illness.  Assess baseline cognition and periodic reassessment Monitor orthostatic blood pressure

Nursing Care plan Monitor for delirium during acute illness Institute fall prevention strategies  Rise slowly from lying, sitting positions; wait 1-2 minuted prior to

transfer

Implications Risk of poor balance, postural hypotension, falls, injury Decreased proprioception; potential for extrapyramidal Parkinson-

like gait Ischemic paresthesia in extremities common Slowed thought processing, response to stimuli, reflexes. Risk of mild cognitive impairment, delirium in acute illness.

XI. Journals

1. Watters, J. M. (2002). Surgery in the elderly. Canadian Journal of Surgery, 45,104–108. Evidence Level V: Literature Review.

2. Krassie, J., & Roberts, D. C. (2001). The independent older Australian: Implications for food and nutrition recommendations. Journal of Nutrition, Health & Aging, 5(1), 11–16. Evidence Level V: Program Evaluation.

3. Conn, V. S., Minor, M. A., Burks, K. J., Rantz, M. J., & Pomeroy, S. H. (2003). Integrative review of physical activity intervention research with aging adults.Journal of the American Geriatrics Society, 51(8), 1159–1168. Evidence Level I: Systematic Review.

4. Fielding, R. A., LeBrasseur, N. K., Cuoco, A., Bean, J., Mizer, K., & Singh, M. A. F. (2002). High-velocity resistance training increases skeletal muscle peak power in older women. Journal of the American Geriatrics Society, 50(4), 655–662. Evidence Level II: Single Experimental Study.

5. Park, H. L., O’Connell, J. E., & Thomson, R. G. (2003). A systematic review of cognitive decline in the general elderly population. International Journal of Geriatric Psychiatry, 18(12), 1121–1134. Evidence Level I: Meta-analysis.

XII. Theory of Application

A major focus of health promotion is to minimize the loss of independence associated with functional decline and illness. The predominant health problems of older adults are chronic rather than acute and are exacerbated by the normal changes of aging and the increased risk of illness associated with old age.

The field of geriatrics/gerontology has matured to the point where there is now a recognized body of literature on care of older. There also now is a consensus in geriatric nursing and medicine as to what constitutes “best practice” in care of older adults. Failure to implement these geriatric care standards for older adults is unacceptable.

The content of this document is organized as follows:

A) Gerontological nursing competency statements necessary for nurses to provide high-quality care to older adults and their families.

B) These 19 gerontological nursing competency statements are divided into the nine Essentials identified in the AACN document The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008), with rationale, suggestions for content, teaching strategies, resources, and glossary of terms.

XIII. Summery

Geriatric Nursing is the best source for clinical information and management advice relating to the care of older adults. Geriatric Nursing is written for nurses and nurse managers who work in hospitals, long-term care facilities, senior centres, or in home care.

A geriatric nurse deals with the effects of aging, as well as the illness that brings the patient to the facility. Diminished hearing or vision, slower mental processing and slower pace are often part of the patient's daily life. The nurse must display patience and understanding, allowing a little more time for answers or action from a geriatric patient.

XIV. Conclusion

End-of-life care can be provided in a health care or home setting, requiring all health care professionals to be aware of the real and potential urologic complications. An individual receiving end-of-life care may encounter many health complications. Whatever the cause, these health symptoms may be distressing to the patient. Consistent with the position of the National Institutes of Health (2004), nursing interventions to manage health complications for these vulnerable individuals must acknowledge individual preference while implementing the intervention that best meets the individual's social, emotional, psychological, and physical needs. It is essential that nurses have an adequate knowledge of how these patients and their families perceive geriatric care to assure interventions are appropriate, respectful, and reflective of each patient's desires.

XV. BIBILOGRAPHY

1. Phipps., Medical & Surgical Nursing., 8th Edition published by Deborah L. Vogel., Page Nos: 10, 20

2. Patricia A. Potter ., Fundamentals of Nursing., 6th Edition published by Elsevier, A division of Reed Elsevier India., Page Nos: 21, 236

3. Barbara Kozier., Fundamentals of Nursing ., 7th Edition published by Pearson Education., Page Nos: 9

4. Kenny, R. A. (2003). Syncope. In W. R. Hazzard, J. P. Blass, J. B. Halter, J. G. Ouslander, & M. E. Tinetti (Eds.), Principles of geriatric medicine and gerontology(pp. 1553–1562).NY: McGraw-Hill. Evidence Level V: Literature Review.

5. Dunn, D. (2004). Preventing perioperative complications in an older adult.Nursing2004, 34, 36–41. Evidence Level V: Literature Review.

6. Mick, D. J., & Ackerman, M. H. (2004). Critical care nursing for older adults: Pathophysiological and functional considerations. Nursing Clinics of North America, 39, 473–493. Evidence Level V: Literature Review.

7. Beyth, R. J., & Shorr, R. I. (2002). Principles of drug therapy in older patients: Rational drug prescribing. Clinics in Geriatric Medicine, 18, 577–592. Evidence Level V: Literature Review.