Gerontology

Geriatrics

Good
Aging
 Vision Changes
Decreased
• visual acuity and visual fields
• lens accommodation
• dark adaptation and depth perception
• color discrimination (blues and greens)
• Tears
• lens elasticity (Presbyopia)
 Assessment Findings
• Arcus senilis - white circle around the iris
• Cataracts - clouding of the normally clear lens
• Macular degeneration - loss of central vision
• Glaucoma - increased intraocular pressure
• Smaller pupil size
• Dry, red eyes
• Vitreous floaters lightning flashes
 Nursing Considerations
• Place objects in the visual field
• Use large lettering to label meds
• Allow more time to focus / adjust to the envir.
• Avoid glare, Use night-lights
• Use red and yellow to stimulate vision.
• Mark the edges of stairs and curbs
• Encourage yrly eye exams
• Encourage use of isotonic eyedrops as needed.
• Encourage use of low vision aids
 Hearing Loss
• Sensorineural - loss of • Increased speech volume
high-tone perception • Turning of head toward
• Conduction deafness - speaker
muffled sounds, Cerumen • Requests of a speaker to
impaction, reversible. repeat
• Hearing loss increases • Inappropriate answers
with age and is greater in (cognitively intact)
men. • become frustrated, angry,
• Decreased speech and depressed
discrimination, esp with • Lack of response to a
background noise. loud noise
 Nursing Considerations
• Hearing test, evaluate ear canals for Cerumen impaction

• Face the person directly so he can lip read. Touch the

person to get his attention before talking.

• Use gestures and objects to help with verbal

communication.

• Speak into the person's “good ear” slowly and clearly.

Allow the person more time to answer your questions.

• Suggest amplifiers on telephones and alarms.

 Smell
• Smell receptors decreases due to sinus dz
• Discrimination of fruity odors persist the longest.
• Inability to notice unpleasant odors
• Decreased appetite

Nursing Considerations
– At mealtime, name food items
– Suggest use of stronger spices and flavorings
to stimulate smell.
 Taste
• Taste buds half gone by 60. 1/6 remain by 80
• Taste buds are lost from the front to the back (ie,
sweet and salty first then bitter and sour).

Assessment Findings

• food has no taste. Uses excessive sugar / salt.

Inability to ID foods. No enjoyment in eating

• Decrease in appetite and weight loss

 Nursing Considerations
• Serve food attractively, and separate
different types of foods.
• Vary the texture of foods.
• Encourage good oral hygiene.
• Season food.
 Kinesthetic Sense
• Change in balance. less able to a fall from
• Shorter step length, less leg lift, a wider
base, and tendency to lean forward.
• Alterations in posture, ability to transfer,
and gait
• Complaint of dizziness
 Nursing Considerations
• Position items within reach.
• Give person more time to move.
• Take precautions to prevent falls.
• Suggest physical therapy with balance
training after periods of prolonged
immobility.
 Cardiovascular
• Thick rigid valves and blood vessels

• Max HR / aerobic capacity decrease. Once elevated,

takes longer to return to baseline.

• Slower response to stress

• Decline in maximum oxygen consumption.

• Normal BP 120/80 mm Hg and below
• BP 121 to 129/81 to 89 mm Hg pre HTN
• BP 130 to 159/90 to 109 mm Hg grade 1 HTN
• BP 160/110 mm Hg and above grade 2 HTN
 Nursing Considerations
• Encourage
– regular BP eval and lifestyle modifications and
medication adherence

– longer cool-down period after exercise

– regular aerobic exercise: walking, biking, or

swimming for 20 minutes at least three times
per week.
 Pulmonary
• Respiratory muscles become weaker,
Decreased elastic recoil of the chest wall
• Total lung capacity unchanged but residual
volume and functional residual capacity
increase.
• Partial pressure of oxygen decreases due to
ventilation perfusion mismatches
• Decreased mucus, foreign body clearance

• Prolonged cough & inability to raise secretions

therefore increased frequency of infections
 Nursing Considerations
• C&DB post surgery

• Avoid crowds during cold and flu season,

wash hands frequently, report early signs
of infection.

• Avoid smoking and exposure to

secondhand smoke.
 Immunologic
• Decline in the immune system (decr T-cell
& B-cell function

Assessment Findings
• More frequent infections
• Increased incidence of many types of cancer
• Teach people that they are at increased risk of
infection, cancer, and autoimmune disease
• Routine follow-up and screening are essential.
 Neurologic
Decreased
• Neurons / no major change in neurotransmitter
levels.
• Brain size / no cognitive impairment.
• muscle tone, motor speed, and nerve
conduction velocity.
• gait speed , step length, stride length, and arm
swing.
• position and vibration sense, diminished reflexes
 Nursing Considerations
• Teach fall prevention techniques
• Environmental safety
– nonslip surfaces
– securely fastened handrails
– sufficient light, glare-free lights
– avoid of low-lying objects, chairs of the proper height
with armrests
– skidproof strips or mats in the tub or shower
– toilet and tub grab bars
– elevated toilet seats.
 Musculoskeletal
• Declining muscle mass and endurance
• Decreased bone density (more in women)
• Decreased thickness and resiliency of cartilage

Assessment Findings
– Muscle atrophy, Increased incidence of fx
– Complaint of joint stiffness in absence of
arthritis
– Decrease bone density
 Nursing Considerations
• Encourage regular exercise
• 20 min of continuous aerobic exercise,
may need stress test before starting
• Encouraged to exercise at a set time, to
relieve pain before exercising
• Promote calcium and vitamin D intake and
decrease alcohol and nicotine use
 Endocrine
• Decreased reaction to stress (pituitary gld)
• Holds fluid - elevated vasopressin (antidiuretic
hormone)
• Normal insulin secretion but decr secretion in
response to a glucose load
Nursing Considerations
– Encourage routine screening of blood glucose
( both fasting and postprandial).
– Provide dietary education about a well-
balanced diet.
 Reproductive
• decreases ovary size / hormone prod
• uterine involution, vaginal atrophy, and
loss of breast mass.
• Risk cystocele, rectocele, and uterine
prolapse.
• Decr testosterone prod / secretion

• Vaginal dryness, painful intercourse

• Atrophic vaginitis, Urinary incontinence

 Nursing Considerations
• Suggest the use of additional lubrication
during sexual intercourse.
• Advise sexually active older men that
spermatogenesis may continue into
advanced age.
• Address poss hormone replacement
therapy for symptomatic relief related to
menopause.
Renal and Body Composition
• Incr body fat and decr lean muscle mass

• Decr renal function, (GFR / creat clear)

• Decr total body creatinine/ serum creatinine

unchanged

• Increased incidence of anemia

• Be aware that although creatinine level may be

within normal range, creatinine clearance may
be decreased.
 Skin
• Thin, fragile, dry skin, fewer melanocytes,
decreased elasticity , Less temp control
• Reduced sensory input, impaired cell-related
immune response.
• Avoid excessive use of soap, use lubrication
• Avoid direct application of extreme hot or cold to
skin because damage may occur without feeling
it.
• Encourage use of sunscreen during all outdoor
activities.
 Treatment for xerosis
– Drink 2,000 mL of liquid daily.

– Total body immersion in warm water (90° to

105° F for 10 minutes.

– Use of nonperfumed soap without

hexachlorophene.

– Apply emollients with alpha-hydroxy acids

after bathing and at bedtime.
 Hematopoietic
• Number of stem cells are unchanged
• Decr bone marrow cellularity and activity
• Nursing Considerations
– Anemia and granulocytopenia are WNL
– No need to take oral iron unless decrease in
iron levels.
– Encourage oral B12 and folate replacement
to manage associated anemias.
 Altered Presentation of Disease
• Manifestations of illness are less dramatic

• Classic indicators of disease are usually absent

or disorders present atypically

• New symptoms are attributed to aging or

existing conditions

• minimize symptoms because of fears of

hospitalization or health care costs.

• Pay attention if the older adult presents with an

acute change in cognition, behavior, or function.
Functional And Psychosocial
Status
 Altered Mental Status
Delirium Dementia
• abrupt in onset • gradual onset
• due to an underlying • Behavior is usually
medical condition stable,
• reversible with • disorientation occurs
treatment of the late
underlying cause
• Acutre behavioral
change
 Depression

• Insomnia, weight loss & anorexia, constipation

• Preoccupation with past life events

• Decrease in concentration, memory, and

decision making (dementia syndrome)
• Musculoskeletal aches and pains, chest pain

• Suicide high in older white men

 Nursing and Patient
• Find Positives
– Encourage participation in meaningful
activities.
– Compliment the person.
– Help the person develop a sense of mastery.
– Encourage reminiscence of meaningful past
events.
• For behavioral problems - aromatherapy,
music therapy, pet therapy, or massage.
Motivation in Elderly Patients
• Base goals on past experiences
• Make short goals daily
• Mastery but do not cause discomfort
• Make sure the environment is right
 Health Concerns
Preventive measures

• Heart disease • Exercise

• Cancer • Arthritis
• Stroke • Falls
• Smoking, Alcohol • Sensory impairment
abuse • Pain
• Nutrition • Medication use
• Dental problems
 Psychosocial Changes and Health Concerns

• Reality orientation • Retirement

• Reminiscence • Social isolation
• Body image • Sexuality
• Acute care • Housing and
environment environment
• Restorative care • Death
environment
 Loss, Grieving, and Death
Terminally Ill Patients Video

Thanatology
Study of death
The description of study of the NC_termillpatients.mov

phenomena of death, and of

psychological mechanisms for
coping with death
 Death and Dying
• Assisting the patient
to “Live well” and “Die
well”

What does this mean to

you?
 Common Fears Of The Dying Patient

• Fear of Loneliness or Fear of Sorrow

• Fear of the unknown
• Loss of self concept and body integrity
• Fear of Regression or Fear of Loss of Self
Control
• Fear of Suffering and Pain

Kübler-Ross Stages of Grieving

• Denial, Anger, Bargaining, Depression, Acceptance
 Recognized
Experienced by others
ACTUAL -
before loss occurs.
Can be actual or
perceived

ANTICIPATORY - SITUATIONAL
TYPES
OF Loss of
job, death
LOSS of child

•-
DEVELOP PERCEIVED
MENTAL

Departure Experienced by one

of children person but cannot be
from home verified by others
 Sources of Loss NC_termillpatients.mov

• Loss of an aspect of oneself

• Loss of an object external to

oneself

• Separation from an
accustomed environment

• Loss of a loved one or valued

person

• Children experience the same

emotions of grief as adults.
Age, Gender and culture
Significance of the loss or cause of
death
Factors Affecting Grief
Spiritual beliefs, support system
Socioeconomic status

Explore and respect values

Interventions Teach what to expect in the grief

process
Encourage expression and sharing of
grief
Encourage the client to resume
activities
 Factors Affecting Grief Response
• Circumstances concerning death
– Sudden, unexpected death
– Lengthy illness resulting in death
– Loss of a child
– Perception that the death was preventable
– Unsteady relationship with deceased
– Mental illness of survivor
– Lack of social support
– Infant, Toddler, Preschool, School Aged, Adolescent
Verbalization of the loss
Crying
Sleep disturbance Normal
Loss of appetite
Difficulty concentrating
Manifestations

Extended time of denial

Depression
Complicated Severe physiologic symptoms
Grieving Suicidal thoughts
 Nursing Strategies Appropriate For Grieving Persons

• Open ended statements and let Pt sets the pace

• Accept any grief reaction, you may be target of anger
• Remove barriers, Avoid giving advice
• Allow patient to talk or express signs of hope
• Support hope by helping focus
 Assist Family to Grieve
• Explain procedures and equipment
• Prepare them about the dying process
• Involve family and arrange for visitors
• Encourage communication
• Provide daily updates
• Resources
• Do not deliver bad news when only one family member is present
 Effects of Culture on Beliefs About Death

• Influence how one reacts to loss, grief, and death

• Governs expressions of grief that is acceptable by the family
• Identifies spiritual beliefs, specific rites, rituals, and practices
that provide comfort
• Nurses need to be in tune with patients’ spiritual needs
• Becoming familiar with cultural views will help
 Cultural Considerations Related to End-of-Life
Issues
• Chinese—to discuss death is taboo, considered bad luck and
evil

• Muslim—illness is a result of sin and death is part of life as

destined by God

• Orthodox Jews—do not leave the dying person alone; have

“minyan” praying at the bedside

• Hindu—may refuse food and pain medication because of

belief in transmigration; head will face east with a lamp near
the head; family will chant (mantra) and pray; they may
spread incense and apply ash to the client’s forehead

• Catholic—priest will anoint the client and give Holy

Communion
 Communicating Truthfully about Terminal
Illness
• Patient has a right to know and the time frame

• The physician will tell the client first

• Nurse assesses what the patient/family have been told

• Choices of Care Setting

• Patient or family have the right to choose where to

care is to be provided
• Hospital, Home/Hospice
 Helping Clients Die with Dignity

• Thorough pain control

• Maintain
independence
• Prevent isolation
• Spiritual comfort
• Support the family
 Assisting Families or Caregivers of Dying
Clients
• Support those who feel unable to care for or be with
the dying

• Show an appropriate waiting area if they wish to

remain nearby

• May be therapeutic for the family to verbally give

permission to the client to “let go” when ready
 Essential Goals of Palliative Care

1. Prevention, relief, reduction, or soothing of

symptoms
2. Allow clients to make informed choices
3. Achieve better relief of symptoms
4. Allow clients the opportunity to work on end of
life issues
5. Allow client to experience a “good death”
 Hospice
• Multidisciplinary, family centered program of care
designed to assist the terminally ill through the phases
of dying

• Physician, RN, LPN, aide, and chaplain are available

to assist the client and family

• Provide many services, such as respite care, medical

equipment, medication

• Services based on need, not ability to pay

Signs/Symptoms of Approaching Death

• Motion and sensation is gradually lost

• Increase in temp, cold clammy skin
• Pulse-irregular, and rapid, decrease BP
• Respirations-strenuous, irregular, Cheyne stokes, “Death
rattle”
• Jaw and Facial muscles relax
• Most positive sign of death=absence of brain waves (Need
two MDs to sign off)
 World Medical Assembly
Guidelines for Death

• No response to external stimuli

• No muscular movement, esp during breathing
• No reflexes
• Flat encephalogram
• In instances of artificial support, absence of brain waves
for at least 24 hours
 Cerebral Death
• Cerebral cortex is irreversibly destroyed
• Permanent loss of cerebral and brainstem function
– Absence of responsiveness to external stimuli, cephalic reflexes,
Apnea
• Isoelectric EEG for at least 30 minutes in the absence of
hypothermia and poisoning by CNS depressants

• Physical Changes of Death

Rigor mortis—stiffening of the body
Algor mortis—loss of skin elasticity
Livor mortis—purple discoloration of skin
 Post-mortem—after death
• The Uniform Determination of Death Act (UDDA)—
defines death as “irreversible cessation of circulatory and
respiratory functions or irreversible cessation of all
functions of the brain, including the brainstem”

• Post-mortem care
– must be done soon after death because of the changes the body
undergoes
– DNR—do not resuscitate
– Omnibus Budget Reconciliation Act (OBRA) of 1986
– Autopsy—postmortem exam to determine the exact cause of
death
– Cultural considerations
 Organ Donation
1. Client must be on life-support to support vital
organs
2. Family must understand that client is brain-
dead
3. No age limit although parents must consent
when client is under 18 years old
4. Indicate on drivers license request to be organ
donor, although family makes the final decision
 Care of the Body After Death
• Check orders for special requests
• Remove equipment and supplies
• Change soiled linens and cleanse patient
• Use room deodorizer
• Place patient in supine position, with small pillow
under head
• Insert dentures
• Remove valuables and give to family
• Stay with family, if requested
 Continued…
• What can be donated?
– Organs—heart, kidneys, pancreas, lungs,
liver, intestines
– Tissue—cornea, skin, heart valves,
connective tissue
– Bone marrow
Organ donation does not affect the
appearance of the body; an open casket is
still possible
 After Client Dies
• Encourage the family to view the body
• May wish to clip a lock of hair as a
remembrance
• Children should be included in the events
surrounding the death if they wish
 Nursing Interventions
• Provide private place for family discussion
• Be sure that the decision is made by the
appropriate person
• Contact local donor registry
• Inform family that body will be cared for
• Be sure family understands that there is
no cost for organ donation
 After The Family Leaves
• Leave wrist ID tag on
• Apply additional identification tags
• Wrap the body in a shroud
• Apply ID to the outside of the shroud
• Take the body to the morgue
• Or arrange to have a mortician pick it up from the
client’s room
• Handle the deceased with dignity
 Autopsy or Organ Donation
• Autopsy - to determine cause of death, coroners case

• For tissue and organ removal:

– Keep CV system going, Call donor bank representative

– Must be agreed on by all family members, patient decision

before death

• Legally person is dead when brain waves cease

– This definition allows for harvesting of organs and tissue for
donation

– Vital organs are: heart, liver, kidney, lung, pancreas

– Non-vital organs are: eye corneas, long bones, middle ear

bones, and skin
 Autopsy
• External Procedure
– Body is brought to the morgue and
photographed and x-rayed as indicated
– Body is cleaned, weighed, and placed on
autopsy table
– The body is placed face up on the table, and
a body block is placed under the patient's
back.
– A general description of the body is made and
all identifying features are noted
 Continued…
• Internal Examination
– A large, deep, Y-shaped incision that is made
from shoulder to shoulder meeting at the
breast bone and extends all the way down to
the pubic bone.
– When a woman is being examined, the Y-
incision is curved around the bottom of the
breasts before meeting at the breast bone.
– The next step is to peel back the skin, muscle,
and soft tissue
Continued…
 Continued…
– The chest flap is pulled up over the face,
exposing the ribcage and neck muscles.
– Two cuts are made on each side of the
ribcage, and then the ribcage is pulled from
the skeleton after dissecting the tissue behind
it with a scalpel.
– A series of cuts are made and organs are
removed and weighed
Continued…
Continued…
Continued…
Autopsy Room
 Post-Mortem Care
• Always follow agency policy and
procedure
• Ensure that correct identification is on the
body
• Remove foley catheters, ET tubes,
oxygen, and peripheral IV’s
• Reinsert dentures if possible. If not, place
them in cup to stay with body
 Continued…
• Position body in natural position, avoid
placing one hand over the other
• Place small pillow under head and elevate
the head of the bed 10-15 degrees
• Close eyes, unless contraindicated by
client’s religious preference
• Shave men unless family requests
otherwise
Good
Aging