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Gerontological Nursing

Gerontological Nursing. Revised by Dr. Maria Park. Introduction:. The Aging population: The world issue Prevalence and scope of the problem Impact of the Baby Boomers. Impact of Aging Population & Gerontological Nursing Issue:. Health status of older adults: Health Care Expenditure & Use

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Gerontological Nursing

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  1. Gerontological Nursing Revised by Dr. Maria Park

  2. Introduction: • The Aging population: The world issue • Prevalence and scope of the problem • Impact of the Baby Boomers

  3. Impact of Aging Population & Gerontological Nursing Issue: • Health status of older adults: • Health Care Expenditure & Use • Health Care Setting: • Nursing home, Residential care, home care

  4. Barriers to health care • Common myths of Aging: • Ageism • Attitudes of caregiver and receiver • Finance • Transportation: reliance on others • Health care reform and it impacts on health care needs for older adults.

  5. Life Transition: • Role Changes • Compound losses: • Widowhood • Retirement • Reduced income • Loss of social prestige • Social isolation

  6. The Aging Process • Factors affecting Aging process: • Heredity • Past and present illnesses • Amount of life stress • Lifestyle - exercise, nutrition, gen. fitness

  7. Theories of Aging: • Biological Theory: • Genetic programming/ Longevity • Somatic DNA Damage theory • Endocrine, immunological • Normal Wear/Tear, • Free Radical, Cross-link theories. • Psychosocial

  8. Process of Aging: • Biophysiological Aging • Psychosocial Aging: • Personality and socioenvioronmental • Past coping mechanisms • adjustment to stressful life event in later life • Adaptation: More difficult for the elderly: • Loss likely to occur close together with less time to adjust to each event.

  9. Process of aging: Psychosocial • Social support and interaction • Sexuality and intimacy • Role transitions and role reverse

  10. Legal/Ethical Issues in Gerontological Nursing • Gerontological care issues • Core ethical concepts in GR • Patient-based principles: Autonomy- right of the individual to hold views, make decisions, and take voluntary actions based on personal preferences and beliefs. • Direct vs delegated autonomy • Competent vs incapacitated autonomy

  11. Legal,Ethical: cont. • Other dimensions of Autonomy • Substitute Judgment • Beneficence and Nonmaleficence • Paternalism: Weak paternalism and strong paternalism.

  12. Legal&Ethical : cont.. • Omnibus Budget Reconciliation Act: • Provision of service requirements:Quality of care • Resident Rights • Do not resuscitate orders • Advanced Medical Directives • Legal Tools: living wills

  13. End of life decision diagram • Person is competent • Right to self-determination • Not competent: substitute decision • Court appointed conservator if needed • The living will speaks • Durable power of attorney: non-life support decisions • Case law: proof of their wishes

  14. Ethical decision making: • Encourage pts’ expressions of desires • Identify significant others who impact & are impacted. • Review personal value system -know self. • Form an ethics committee • Consult: clinical ethics consultation- mediate moral conflict. • Read, discuss, share, evaluate decisions.

  15. Laws governing GN practice: • Legal risks facing Nurses: • Legal liability for Nurses: • Assault and Battery • Negligence • False Imprisonment • Invasion of Privacy • Defamation of Character • Larceny

  16. Practice Setting / Competency requirement • Nursing in the Acute Care Setting • Specific competency and Expertise • Critical Care and Trauma Care • Special Care-related Issues • Home Care and Hospice • Community-based Services

  17. The Role of the GN: • Implementation of the plan of TX: • The Nurse’s Role • OASIS : an assessment toolcare • The Role of the Nurses • OASIS

  18. Standard used in Gerontological Nursing: • ANA Standard of Practice for GN • Scope and major roles in GN • GN practice setting • Issues concerning GN

  19. ANA Standard of CLINICAL GN Care • Standard 1: Assessment • Standard 11: Diagnosis • Standard 111: Outcome Identification • Standard 1V: Planning • Standard V: Implementation • Standard V1: Evaluation

  20. Introduction to Mental Health and Illness among Older Adults

  21. Depression • Incidence: Depression and Suicide • Major depression and depressive symptoms affect eldery 20-40% in U.S. • Incidence: inc. among women and who are medically,emotionally ill or in long-term care. • Age appropriate assessment and Dx.

  22. Barriers to Mental Health Care • Attitudes: Do not seek help as needed. • Finance:Limited income of elders. • Transportation: Elders rely on others • Inadequate detection of MI & TxSeek GP, not psychiatrist: somatic C/P results in misdiagnosis.

  23. Differential Diagnosis:Depression • Differentiating Physical from Mental Illness • Differential DX between Depression and Dementia • PSEUDODEMENTIA: The phenomenon of depression appears to be demented. • Drug Interaction and Side Effects: Needs for drug inventory

  24. Assessment of Pt.with Depression • Health Hx, Medical Illnesses, • Medication inventory, • Mental Status Assessment including Risk for suicide. • Physical Assessment: Energy level and level of independence - ADL • Psychosocial Assessment: Psychosocial stressors, and Coping ability • Laboratory and other diagnostic tests: EEG, ECG, Chem. Profile, CBC, B12 level, CAT, MRI, Serologic tests, Thyroid panel, urinalysis.

  25. Clues /Warning signs of Suicide • Verbal Clues: • Behavioral Clues: • Situational Clues: • Recent move ( to a nursing home, relative’s) • Death of a spouse • Diagnosis of terminal illness

  26. Geriatric Depression Scale(GDS) • GDS: best tool specifically designed to use for older adults. • It consists of 30 questionnaire • Direction: Present questions “VERBALLY”.Circle answer given by pt. Do not show to pt. • 21-30= severe depression • 11-20= mild-mod . 0-10= considered normal • .* GDS scale available in reserve section.

  27. GDS scale: limitation: Not applicable for severely demented pt. • The GDS is not a substitute for a diagnostic interview. • GDS is a screening tool for assessment of depression in older adults.

  28. Depression Secondary to Medical Illness • How prevalent is depression in the medically ill patient? • Up to 17% of adults • ECA study 9.4-12.9% of medically ill patients experienced depression in comparison to 5.8-8.9 in a matched control group of healthy individuals ( wells, et al. 1998).

  29. Under-diagnosis & Under-treatment • Depression in the medically ill patients are under-diagnosed and under-treated: • Only 34.9% of pts with major depressive disorder were identified and adequately treated by their primary care physicians( Coyne et al 1995)

  30. Depression secondary to Medical Illness: • Characteristics of: • Older age at onset • More likely to respond to ECT • More likely to show “organic” features in Mental Status Exam. • Less likely to have SI or commit suicide (18 vs45) * Winokur, ‘90

  31. Common Medical Conditions Etiologically R/T Depression • CA • endocrine disorders • End stage renal disease and Hemodialysis • Neurological disorders

  32. Common Medications Assocwith Depression • Antihypertensives • Benzodiazepines ( Anti-anxiety meds) • Cancer- chemotherapeutic agents • Contraceptives • Corticosteroids • Histamine 2 receptor antagonist: • Cimetadine(Tagamet) • Ranitidine(Zantac)

  33. Psychoactive substances Assoc.with Depression: • Alcohol • Amphetamine (withdrawal) • Anabolic steroids • Cocaine (withdrawal) • Opiates

  34. Polypharmacy in the Tx of Older Adults: • Issues concerning polypharmacy in the elderly: • Prevalence • Prevention strategies

  35. Nursing Care Plan • Presenting problems and the risks: • Leading Dx for Older Adults with Depression, and suicidal tendency: • Outcome criteria: • Intervention plan:

  36. TX of Depression in the Medically ill Pts • Assessment of pt to identify mimicking problem • Intervention strategies • Psychopharmacologic management: • SSRI’S, NSSRI’s, TCA’S

  37. Treatment of Depression: Elders • Somatic Tx.:* Consider pharmacodynamic changes in the Elderly: Adverse drug reactions &interactions: • Antidepressants: Use with the lowest level of anticholinergic effect. • Second gen. Antidepressants with low anticholinergic effects: Zoloft and Paxel, • Mood stablizer: Divalproex NA ( Depakote) • Benzodiazepines • ECT

  38. SSRI’s and NSSRI’S • Sertraline –Zoloft Venlafaxine –Effexor • Paroxetine- Paxil Mirtazapine –Remeron • Escitalopram –Lexapro • Fluvoxamine –Luvox • Citalopram –Celexa • * Remeron increases norepinephrine and serotonin through blockade of inhibitory receptors. * Fluoxetine – Prozac is not commonly prescribed to older adults because of long half-life.

  39. Psychosocial Approach:Depression • I:l N/T interaction: develop trusting relationships. • Overcome barriers (Ageism, attitudes) • Improve pt’s self-esteem: • Help improve appearance • Acknowledge any progress pt made. • Encourage socialization - Dec. anhedonia. • Focus on here-and now: A graded system. • Milieu management • Reminiscence Therapy • Cognitive Behavioral Therapy

  40. Normal Changes with Aging: • Cognitive function • Personality and Self-Concept • Stress and Coping

  41. Aging and Cognitive Changes: • Pathology begins • _55__60_65__70__Onset symptoms________ • Loss of ADLs • _________________ 75 80 85 <85 • _______/___________/_________/__90 <90 Normal ProdromalSymptomaticDeath

  42. Prevalence of Dementia: Increase with Age

  43. Cognitive Mental Disorders: Organic • Dementia:Permanent, chronic progressive form of CMD developed over an extended time. • Incidence & Prevalence: Alzheimer’s disease is the most common form of dementia (50-70%). • Multi-infarct dementia:By repeated strokes. • Small # caused by neurological disorders: huntington, Parkinson’s, and head injury. • Alcoholism, drug overdose, malnutrition. • Infectious diseases: HIV

  44. Etiology • Genetic • Biological: loss of neurons in the brain cerebral cortex and Hippocampus. • Neurofibrillary tangles • Amyloid plaques • Environmental

  45. Diagnostic Test • Spinal fluid analysis for b-amyloid measure • Neuronal thread Protein (NTP) measurement. • Postmortem autopsy. • Differential DX: • Alzheimer’s D vs other organic dementia • Alzheimer’s D vs Psuedodementia

  46. Cognitive Testing :Mini-Mental State Exam(MMSE): • Score 5/5 Orientation • Score 3 Registration • Score 5 Attention & Calculation • Score 3 Recall • Score 9 Language • Total score: • Assess level of consciousness: • Alert Drowsy Stupor-coma

  47. Cognitive Testing: Clock Draw • CLOX(Clock) • Measure the executive control function(ECF) • eg: goal selection, motor planning, sequencing, selective attention. • Directions: Ask the pt to draw a clock: • Start by drawing a large circle • Fill in all the numbers on a clock • Set the hands to show the time 8:40

  48. Cognitive Testing: Mini-Cog • 3 item recall and clock drawing: • Directions: • Say 3 categorically unrelated words (like MMSE) • Ask pt to repeat back to you and remember them • Give the clock drawing test • Ask the pt to tell you the 3 words again

  49. Cognitive testing: Mini-cog • Mini-cog • Recall=0 Recall=1-2 Recall=3 • Clock abnormal Clock normal • Demented Non-demented

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