medical surgical nursing

1. Gerontological and Geriatrics Nursing
• An encompassing view of the care of older adults
• Providing both physical and emotional support in addition to
respectful care

2. Myths
• Elderly people are incompetent and incapable of making
decisions or handling their own affairs.
• Most elderly live in nursing homes
• All elderly people live in poverty
• Older people are lonely and unhappy
• Elderly do not want to work
• “Old Age” begins a 65
• Retirement ends your active life

3. Gerontology is the study of the aging processes and individuals as they
grow from middle age through later life.
It includes:
– the study of physical, mental, and social changes in older people
as they age
– the investigation of the changes in society resulting from our
aging population
– the application of this knowledge to policies and programs.
– As a result of the multidisciplinary focus of gerontology,
professionals from diverse fields call themselves
"gerontologists“
Geriatrics is:
• the specialty that concerns itself with the provision of nursing services to
geriatric or aged individuals.
• the study of health and disease in later life
• the comprehensive health care of older persons and the well-being of their
informal caregiver.
The aging population

4. Old Defined
• Young old: 65 – 74
• Middle old: 75 – 84
• Old old: 85 and up
• Only a guide as there is a vast difference in
biological and chronological aging

5. Continuum of Care
• Multitude of settings for those > 65
– 48% in hospital requiring care
– 80% receiving home care
– 90% in nursing homes receiving care
• Acute Care Hospital
• Acute Rehab
• Home Health Care
• Alzheimer’s Care – preserve functional status
• Hospice
• Respite Care
• Continuing Care Retirement Community
– Independent living to skilled care
• Assisted Living
• Foster Care or Group Homes
• Adult Daycare

6. The Numbers
• Steady increase in older population
• In 2006, 37 million people age 65 and over lived in the United
States, accounting for just over 12 percent of the total
population.
• The older population in 2030 is projected to be twice as large as
in 2000, growing from 35 million to 71.5 million and
representing nearly 20 percent of the total U.S. population.
• Why they increase?
– Improved sanitation
– Advances in medical care
– Implementation of preventive health services
– In 1900s, deaths were due to infectious diseases and acute
illnesses
– Older population now faced with new challenge
• Chronic disease
• Health care funding

7. • Heredity
• Nutrition
• Health Status
• Life Experience
• Environment
• Activity
• Stress
Nurses must understand the multitude of factors that influence the
aging process and recognize the unique outcomes for each
individual.
Factors Influencing the Aging Process

8. Some Facts
• Female to male ratio increases with age
• Higher education equates to more money, higher
standards of living, and above-average health
• Older people who live alone are more likely to live in
poverty
• Significant increase in proportion of minorities
– More racially and ethnically diverse
• Aging disabled population
– Traumatic injuries
– Developmentally disabled
– Elderly inmates
• Elderly begins at 50 due to stresses of prison life

9. Mortality and Morbidity
• Heart disease and cancer are two top causes of death,
regardless of age, race, gender or ethnicity
• Chronic Disease
– Increases with age
– 4 leading causes of death
• Heart disease-33%
• Stroke-8%
• Cancer-22%
• DM
– Sensory impairments and oral health problems more
frequent

10. Aging Well
• 72% of seniors report having good to excellent health
• Numbers living in nursing homes has declined
• 1 out of every 5,578 people was 100 yo or older
• Older adults are active and healthy
Successful aging
• Achievement of sense of autonomy, dignity, and absence of
suffering
• New England Centenarians study
– Avoided chronic/acute diseases
– Successfully navigated through obstacles and the
physical/psychosocial challenges
• Healthy People 2010 – to increase the quality and quantity of
a healthy life
• A positive view of aging as a normal process is needed

11. • Ageism- “the prejudices and stereotypes that are applied to older
people sheerly on the basis of their age…”
• Changes in Family Roles and Relationships- Parenting and
grandparenting
• Loss of a Spouse- affects more women than men because women
tend to have a longer life expectance than men; many are widowed
by their eighth decade of life.
• Retirement- Loss of the Work Role and Reduced Income
• Changes in Health and Functioning- changes in appearance and
bodily function occur
• Cumulative Effects of Life Transitions- Shrinking Social World and
Awareness of Mortality
• Responding to Life Transitions- Life Review, Life Story and Self
Reflection, and Strengthening Inner Resources
Life transitions and Story

12. Aging Theories
• The biological, psychological, and social processes of
aging are interrelated and interdependent.
• Cultural, spiritual, regional, socioeconomic,
educational, environmental factors, and health status
impact the older adults perceptions and choices about
their health care needs
• Limited work has been done to identify nursing-specific
aging theories
• Aging is a distinct discipline that requires aging theories
that have an interdisciplinary perspective

13. Types of Theories
• Psychosocial: Attempt to explain aging in terms of
behavior, personality, and attitude change
• Encompass psychological and sociological theories
• Psychological: How mental processes, emotions,
attitudes, motivation, and personality influence
adaptation to physical and social demands
• Sociological: How changing roles, relationships, and status within a
culture or society impact the older adult’s ability to adapt
• Activity theory – central theme that remaining active in old
age is desirable
• Disengagement theory – characterized by gradual withdrawal
from society and relationships
• Biological: Explain the physiologic processes that change with aging
– Free Radical Theory – aging caused by effects of free radicals
– Wear and Tear Theory – cumulative changes occurring in cells
age and damage cellular metabolism

14. Maslow’s Hierarchy of Human Needs Theory
Although Maslow doesn’t specifically address old age, it is clear that
physical, economic, social, and environmental constraints can impede
need fulfillment of older adults.

15. Aging theory summary
Genetic
– Aging is controlled by genes
– Programmed senescence
• Wear and tear
– Environmental factors result
in cumulative damage to
molecules and cells
– Protective and repair
mechanisms fail
Inflammatory process
 The balance between
 pro-inflammation (naturally selected
to keep people alive until
reproduction) versus
 modulators of the inflammatory
response (necessary to reduce
collateral damage)
 affects longevity

16. Implications of aging theories
• Past experiences in life
• Health beliefs & values
• Adjustment to limitations
• Indications for wellness
• Changes view of aging equates to illness

17. Nursing Theories
• Need to take human aging into consideration
• Need to develop a more situation-specific theory of aging to guide
practice
• Nursing practice must be comprehensive yet consider individual
differences
• Must be holistic and take into account all that impacts on a person
throughout a lifetime of aging
• Functional Consequences Theory
– A guiding framework that would address older adults with physical
impairment and disability
– Nursing’s role is to minimize age-associated disability in order to
enhance safety and quality of living
• Theory of thriving
– Based on the concept of failure to thrive and application of thriving to
the experience of well-being among frail elders living in nursing
homes
– Nurses identify and modify factors that contribute to disharmony
among a person and his or her physical environment and personal
relationships

18. 1. Evidence-Based Practice= practice has moved
from trial and error to following a systemic
approach that uses existing research for clinical
decision-making= a process known as
evidence-based practice
2. Standards= Professional nursing practice is
guided by standards. Standards serve to both
guide and evaluate nursing practice.
3. Principles= Nursing principles are those proven
facts or widely accepted theories that guide
nursing actions.
Core Elements of Gerontological Nursing Practice

19. • Healer- Nightingale wrote “nursing put the patient in the best
condition for nature to act upon him”.
– As medical knowledge and technology grew more sophisticated
and the nursing profession became grounded more in science
than in healing arts, the early emphasis on nurturance, comfort,
empathy, and intuition was replaced by detachment, objectivity,
and scientific approaches.
• Caregiver- active participation of older adults and their significant
others and promotion of the highest degree of self-care.
• Educator- Nurses must take advantage of formal and informal
opportunities to share knowledge and skills related to the care of
older adults
• Advocate- For individual older adults, and to facilitate a
community’s efforts to affect change
• Innovator- Nurses need to think “out of the box” and take risks
associated with traveling down new roads, and transform visions
into reality.
Gerontological Nursing Roles

20. Advantages of Learning Geriatric Care
• Learning patience, tolerance, understanding, and basic
nursing skills
• Witnessing the terminal stages of disease and the
need for skilled nursing care
• Preparing for the future because the aged will always
be a part of the care you provide
• Recognizing the importance of rehab
• A need for research

21. Therapeutic Communication
• Ongoing, continuous, dynamic process
• Includes verbal and nonverbal signals

22. Communication
Nonverbal
• 80% of communication
process
• Body language
• Positioning
• Eye contact
• Touch
• Tone of voice
• Facial expressions
Verbal
• Do not yell or speak too loudly
• Communicate at eye level
• Minimize background noise
• Monitor patient’s reaction
• Use touch as appropriate
• Supplement verbal instruction with
written instructions
• Guidelines
– Avoid long, complicated instructions
– Determine how patient would like to be
addressed
– Use caring responses and caring listening
– Encourage reminiscing

23. Barriers to Communication
• Fear of one’s own aging
• Fear of showing emotion
• Fear of missing something
• Fear of being called on to rectify every problem
• Lack of knowledge of patient’s culture, goals, and
values
• Unresolved issues with aging relatives in own family
• Feelings that professional distance must be maintained
• Being overworked, or overscheduled

24. • Gerontological Nursing Practice is governed by the law
• Because laws are developed at the state and local levels, variation
exists among the states.
–Constitutions- basic rights, grant powers, and place limits on
government agencies
–Court decisions- establish precedents from cases heard in state or
federal courts
–Statutes- established by local, state and federal legislation (nurse
practice acts)
–Regulations- laws enacted by state and federal agencies that define
the methods to achieve goals (conditions for agencies to receive
reimbursement from Medicare or Medicaid)
–Attorney General Opinions- laws derived from the opinions of the
chief attorney for the state or federal government
Legal aspects of gerontological nursing

25. •Negligence- omission or commission of an act that
departs from acceptable and reasonable standards,
which can take several forms:
•Malfeasance- unlawful or improper act (surgical
procedure)
•Misfeasance: performing an act improperly (no
signed consent)
•Nonfeasance: failure to take proper action
•Malpractice: failure to abide by the standards of
one’s profession (not checking that a NG tube is in
the stomach before administering a tube feeding)
•Criminal negligence: disregard to protecting the
safety of another person (allowing a confused patient
to have matches)
Acts that could result in legal liability for nurses

26. • Guardianship- court appointment of an individual to have the
authority to make decisions for an incompetent person
• Power of Attorney- Competent individuals appoint parties to
make decisions for them
• Restraints- chemical and physical
–Anything that restricts a patient’s movement can be
considered a restraint
–Alternatives should be used whenever possible-
alarmed doors, wristband alarms, bed alarm pads, beds
and chairs close to the floor, increased staff and
supervision
–When restraints are necessary, a seniors’ order must be
obtained- must include the type of restraint, condition
of patient, and duration of use
•
Reducing the Risk of Malpractice

27. • Terminally ill patients that are going to die and resuscitation attempts
would not be therapeutic
• A physician order must be obtained to clearly state the wishes for no
resuscitation- it is negligence to withhold CPR without an order
• DNR at bedside is not valid without an official order
• Advance Directives or a Living Will:
–Protects the patients right to make decisions about terminal
care
–Express the desires of competent adults regarding terminal
care, life-sustaining measures, and other issues pertaining to
their death and dying
–1990- Patient Self-Determination Act- requires all health
care institutions receiving Medicare or Medicaid funds to ask
patients on admission if they possess a living will for health
care
No-code orders

28. • Many forms- inflicting pain or injury; stealing, mismanaging funds,
misusing medications, causing psychological distress, withholding
food or care, sexual abuse, confinement
• Threatening to commit these acts is a crime
• Nurses have a legal responsibility to report cases of known or
suspected abuse
Ethical Aspects of Gerontological Nursing
 The concept of accepted standards of conduct and moral judgment
Elder abuse

29. – Older persons face the same environmental hazards as any adults,
but their risks are compounded by age related factors that reduce
their capacity to protect themselves from and increase their
vulnerability to safety hazards.
– Age related changes can reduce the capacity of older adults to
protect themselves from injury and increase their vulnerability
(Key Concept)
– Accidents rank as the sixth leading cause of death for older
adults- falls is the leading cause
safety

30.  Environment can be considered in two
parts-
1. Microenvironment- our immediate
surroundings with which we closely interact
2. Macroenvironment- elements in the larger
world that affect groups of people or entire
populations
Importance of the Environment to Health and
Wellness

31. • Potential Environmental Impact of Various Physical
Limitations
• Assessing basic standards for older adult’s
environment
• Lighting= function, orientation, mood and behavior
• Temperature= because older adults have lower normal
body temperatures and decreased amounts of natural
insulation, they are especially sensitive to lower
temperatures.
• Colors= red, yellow, and white can be
stimulating/blue, brown, and earth tones can be
relaxing
» Orange?
» Green?
» Black? Grey?
Impact of Aging on Environmental Safety and
Function

32. • Age-related changes-
• Improper use of mobility aids-
• Medications-
• Unsafe clothing-
• Disease-related symptoms-
• Environmental hazards-
• Caregiver-related factors-
Falls- Risk and Prevention

33. • Effects of Aging on Medication Use:
– Polypharmacy- The high prevalence of drugs
consumed by older people and the complexity of drug
dynamics in old age require geri nurses to evaluate the
effects of drugs
– Altered Pharmacokinetics- absorption, distribution,
metabolism, and excretion of drugs.
• Absorption- decreased gastric blood flow and motility,
slower metabolism
• Distribution- dehydration will decrease drug distribution,
and lower dosage levels may be necessary
• Metabolism, detoxification, and excretion- the renal system
is primarily responsible for the body’s excretory functions.
Drugs are not as quickly filtered from the blood stream and
are present in the body longer.
Safe medication use

34. • Avoiding Inappropriate Drugs
• Reviewing Necessity and Effectiveness of Prescribed Drugs
– Why is drug ordered?
– Is the smallest possible dosage ordered?
– Is the pt. allergic?
– Can this drug interact with other drugs?
– Special instructions?
– Most effective route?
• Promoting Safe and Effective Administration
• Encourage good oral hygiene, fluids, proper positioning to
facilitate swallowing
• Frequently an older person will bleed or ooze after an injection
because of decreased tissue elasticity.
Provide Patient Teaching
• Assess a patient’s risk for medication errors
Promoting the Safe Use of Drugs

35. Summary
Potential Negative Effects Society Places on the
Aged
 Aging as an illness
 Loss of autonomy
 Loss of individuality
 Isolation
 Deprivation of intimacy
 Dependency issues

36. Normal Aging
 Aging is NOT an illness
 Slowing of the body’s functions
 Impact of chronic illness
 Physiological changes that accompany aging may
alter the way an individual responds to stress and
disease

37. Physical Changes Related to Aging
•Many physiologic changes are not related to aging or
disease states but to individual differences, e.g.:
•Some 100 year old marathon runners have no arthritis or
cartilage loss
•Many 80 year old men and women frequently engage in
normal sexual expression
•There is no reason to necessarily expect pulmonary, cardiac,
intestinal, renal reserve to degenerate simply because of aging
•While the incidence of dementia increases with age cognitive
decline is a disease not normal aging