1. Ageing and Community Nursing
By Dr. N. Haliyash, MD, BSN

2. Ageing
In almost every country, the proportion of people aged over 60 years is growing faster than any other age group, as a result of both longer life expectancy and declining fertility rates.

3. Classification of Older Adults
Older adults are 65-years-old and older
young old
middle old
old-old (fastest growing subgroup)
elite old

4. Health Care of the Older Adult (continued)
50% of hospitalized clients on med-surg units are older than 65
8% of elderly have 1 or more chronic illnesses
50% have 2 or more chronic illnesses
5% live in institutional settings

5. Assessment Guidelines for Older Adults
Adjust to physiologic changes
Be familiar with sensory changes, changes in each body system
Adapt assessment techniques to diminishing energy and ability
Allow for frequent breaks if a lengthy assessment is needed

6. Assessment Guidelines (continued)
In addition to physical assessment, the older adult may need assessment of:
Ability to perform ADL’s (Activities of Daily Living - functional assessment)
Network of support (family and friends)
Health beliefs in nutrition, exercise, etc.
Sleep patterns
Living arrangements
Financial assessment
Self-esteem
View of life and acceptance of death

7. Reminiscence/Life Review
An adaptive function that allows them to recall the past and assign meaning to these experiences
Can be a nursing intervention to encourage self-esteem, increase communication skills, and increase social interaction

8. Pain and the Older Adult
May not report pain as feels it is a part of aging
85% of patients in nursing homes have pain
Pain response: have similar pain tolerance as young adults

9. Pain Assessment Use methods as with adults (pain scale)
Don’t assume that if patient is busy or sleeping, they don’t have pain; need to ask them
If cognitive impairment is present, watch for non-verbal cues
Agitation
Aggression
Wandering
Change in vital signs
Grimacing

10. Pain Management Ask what they usually use for pain and is it working
If acute pain, can use narcotics but may need a decreased dose

11. Medications and the Older Adult
25% of all prescriptions are written for people older than 65
Physiologic changes caused by aging affect the activity and response of drugs
Absorption, distribution, metabolism, excretion

12. Polypharmacy
Many older adults are using multiple medications, use multiple pharmacies, have multiple physicians
Multiple drugs may lead to adverse reactions

13. Polypharmacy Most common adverse reaction in the elderly is confusion
Confusion in the absence of disease is
not normal!!

14. Nursing Interventions for Polypharmacy
Assess medications they are taking
Encourage client to use one pharmacy for all medications
Encourage client to review with primary caregiver all medications they are taking

15. Medication Noncompliance in the Older Adult
May be non-compliant due to:
Not understanding how to take medication
Forgetful
Don’t like the side effects
Don’t have the money to purchase medications

16. Nutrition and the Older Adult
Risk of nutritional problems increases with age
Energy needs decrease but nutrient needs remain the same

17. Causes of Malnutrition in the Older Adult
Loss of teeth
Digestive system changes
Loss/decrease of appetite
Lactose intolerance
Fixed income
Lack of socialization during meals

18. Nursing Interventions to Improve Nutrition
Small, frequent meals
Assist with food choices
Identify causes of decreased appetite
Refer to dentist for teeth issues
Refer to social services for financial problems
Discuss ways to improve socialization during meal time

19. Goals for Older Adults Follow therapeutic plan of care
Ensure transportation to MD visits
Ensure primary physician is aware of all medications currently taking
Maximize independence in self-care activities
Educate about resources to assist them with care if needed

20. Goals (continued) Maintenance of ability to communicate
Educate about assistive devises such as hearing aids
Assist with financial counseling to help pay for these aids if needed

21. Goals (continued) Maintenance of positive self-image
Assist the patient to participate in appropriate social activities to enhance the feeling of worth
Encourage open expression of concerns such as feelings of hopelessness

22. Goals (continued) Remain free of injury In the hospitalized patient
Perform fall risk assessment
Orient to surroundings and re-orient as needed
Provide assistance with ADL’s

23. Goals (continued) Maintain bowel and bladder elimination patterns
Discuss nutrition to promote elimination
Discuss use of medications if prescribed
Urinary incontinence (loss of bladder control) is a symptom, not a disease.

24. Goals (continued) Maintain adequate nutritional status
When hospitalized
Intake and output
Daily weight
Dietary referral for preferences
Socialization
Assist with feeding
Liquid supplements as needed

25. Goals (continued) Maintain adequate fluid and electrolyte status
Place water within easy reach of the client
Offer fluids every 1-2 hours
Monitor electrolytes
Intake and output
Administer and monitor IV fluids if needed

26. End-of-Life Issues Death and Dying
Nurses must recognize influences on the dying process
Legal
Ethical
Religious
Spiritual
Biological
Provide sensitive, skilled and supportive care

27. End-of-Life Issues (continued)
Both the patient who is dying and the family members grieve as they recognize the loss
Nursing Diagnosis of Anticipatory Grieving includes:
Denial worthlessness
Anger concentrate
Feelings of guilt
Inability to concentrate

28. End-of-Life Legal Issues
Medical Directive to Physician (Living Will)
Addresses only the withholding or withdrawal of medical treatment that would artificially prolong life
Becomes effective when the primary physician and one other doctor say in writing that an individual is in a terminal or irreversible condition and that death will occur if life-sustaining medical care is not given
Some states allow for personal instructions to be added to this document

29. End-of-Life Legal Issues (continued)
Advanced Health Care Directive
Used to be called Durable Power of Attorney
An Advance Directive that allows an individual to appoint representatives to make health care decisions if they become incapacitated
This document affects only health care and should not be confused with granting power of attorney for other matters
Becomes effective when the person becomes terminally ill or incapacitated.

30. Nursing Responsibility for Advance Directives
Each state varies; nurses need to be aware of requirements for their state
Be prepared to answer questions from the patient about these directives
Ask if your patient has these and make sure copies are placed in their charts
Advance Directives must be honored

31. End-of-Life Issues (continued)
Artificial Nutrition and Hydration is another important ethical and legal issue
Feelings about withholding food and fluids are emotionally charged and often have religious connotations.
U.S. Supreme Court has upheld the right of patients to accept or reject the administration of artificial nutrition and hydration.

32. End-of-Life Issues (continued)
Hospice Care
Focuses on support and care of the dying person and family
Goal: to facilitate a peaceful and dignified death
Based on holistic concepts
Improve quality of life rather than cure
Support patient and family

33. Hospice Care (continued)
Principles of hospice care can be carried out in a variety of settings
Home and hospital are the most common settings
Palliative care: differs from hospice in that the client is not necessarily believed to be dying

34. Nursing Care of the Dying Patient
Provide personal hygiene measures
Relieve pain
Essential for patient to maintain some quality in their life
Assist with movement, nutrition, hydration, elimination

35. Nursing Care (continued)
Provide spiritual support
Arrange access to individuals who can provide spiritual care
Facilitate prayer, meditation and discussion with appropriate clergy or spiritual advisor

36. Nursing Care (continued)
Support patient’s family
Use therapeutic communication to facilitate their feelings
Display empathy and caring
Educate family on what is happening and what the family can expect
Encourage family members to participate in the physical care of the patient

37. Do Not Resuscitate Also called DNR, No Code Must be written
Must be reviewed regularly as per policy
May have specific requests
Example: may okay vasopressors and fluids but no chest compressions or intubation

38. Q & A ?
This population ageing can be seen as a success story for public health policies and for socioeconomic development, but it also challenges society to adapt, in order to maximize the health and functional capacity of older people as well as their social participation and security.
This population ageing can be seen as a success story for public health policies and for socioeconomic development, but it also challenges society to adapt, in order to maximize the health and functional capacity of older people as well as their social participation and security.